SCienCe OF MediCine

sleep in the elderly

by Prathusha Tatineny, MD, Fariha Shafi, MD, Ashraf Gohar, MD & Abid Bhat, MD

Older people have abstract when persistent, can lead to

difficulty in falling asleep Aging is associated with daytime sleepiness, which can lead
and staying asleep due several changes in sleep patterns. to morbidity in elderly people,
to frequent arousals. it is Older adults have increased such as impaired cognition,
important to know how prevalence of primary sleep disorientation, delirium, as well
sleep patterns change disorders including insomnia, as increased risk of falls. Patients
as we age and, at the sleep disordered breathing, with sleep disorders are often more
same time, to recognize restless legs syndrome, REM sleep likely to develop cardiovascular
primary sleep disorders behavior disorder, and circadian and cerebrovascular disorders,
among the elderly rhythm disturbances. These and individuals with a history of
people. can be further compromised by these medical disorders are often
sleep disturbances secondary to at a high risk of developing sleep
medical or psychiatric disorders, disorders. Sleep disturbance in
and medication side effects. the elderly should be considered
This review discusses age-related a multifactorial geriatric health
changes in sleep architecture, condition, requiring consideration
etiology, clinical presentation, of multiple risk factors and
and treatment options of various a comprehensive treatment
sleep disorders in the elderly. approach.3 In this review, we will
focus on common sleep disorders,
introduction along with the diagnostic and
Sleep is an important aspect specific treatment options to help
for health and wellness across the improve quality of life in the elderly
lifespan. The number of people population.
in the United States who are 65
years or older is steadily increasing, sleep Changes with aging
and is expected to double over As part of the natural aging
the next 25 years to about 72 process, sleep becomes more
million. By 2030, roughly one in fragmented and lighter with
five people in the US will be over an increase in the number of
the age of 65.1 Sleep physiology EEG arousals and awakenings
changes with the age, and many which result in reduced sleep
sleep disorders increase in the efficiency and total sleep time.4
Prathusha Tatineny, Md, is a Former elderly. As many as 50% of older Several changes occur in both
Fellow, Sleep Medicine Fellowship adults, compared to 15.9 to sleep architecture as well as
Program, University of Missouri - 22.3% of the general population,
Kansas City School of Medicine,
sleep parameters throughout the
Kansas City, Missouri. Fariha Shafi, complain about sleep problems.2 lifespan.5 (Table 1.) The percentage
Md, MSMA member since 2020, and In the elderly population, a large of stage N1 and stage N2 along
Ashraf Gohar, Md, are Associate
Professors, and Abid Bhat, Md,
contributing factor to poor sleep with time spent awake during
(above), MSMA member since 2020, is the high prevalence of medical the night increases with aging
is Professor; all are in the department and psychiatric comorbidities while there is a reduction in sleep
of internal Medicine, University
of Missouri-Kansas City School of in addition to the issue of efficiency and slow-wave sleep
Medicine, Kansas City, Missouri. polypharmacy. Sleep complaints percentage. The elderly tend to

490 | 117:5 | September/October 2020 | Missouri Medicine

TABLES:
SCienCe OF MediCine

Table 1. Age-Related Changes to Sleep Architecture

Increased Decreased
Sleep Latency Sleep efficiency
Sleep Parameter Time awake after sleep onset (WASO) Total sleep time
Number of arousals from sleep Slow wave sleep

go to bed earlier and wake up earlier when compared and decreased daily activity. A number of primary sleep
to young
Table adults.ofThe
2. Causes poorshift
sleepininsleep times isSubjects
the Elderly due to the disorders including restless leg syndrome, periodic
circadian rhythm generated by the pacemaker that is limb movement disorder, sleep apnea, and rapid eye
Physiologic Age related changes in sleep efficiency
located in the suprachiasmatic nucleus (SCN) of the movement sleep disorder can present as insomnia. Also,
Medical Disorders Cardiopulmonary disorders,
hypothalamus. Aging is associated with a decrease
Arthritis, or many medications (e.g., beta blockers, bronchodilators,
malfunction in sensitivity of the SCN to environmental
Chronic pain syndrome, anticholinergics, antihypertensives, antidepressants, and
cues to adjust circadian rhythm to aNeurodegenerative
natural 24-hour disorders stimulants) cause or exacerbate insomnia.12
Gastroesophageal reflux disorder
day/night cycle. Melatonin levels also diminish with Due to the high prevalence and negative
Psychiatric Disorders Depression,
age and reach levels similar to daytime concentrations
Anxiety Disorder consequences of insomnia in older adults, screening for
which may contribute to the increased
Behavioral prevalence
Excessive of
napping, insomnia and other sleep disorders should be included
sleep-related disorders with aging.6 The Use of caffeinated
amplitude of beverages,
in the including alcoholevaluation. It is important for
routine clinical
Medications Diuretics, Beta-blockers, Anti-depressants
circadian rhythms, including those of body temperature clinicians to take a detailed history from patients and
Primary sleep disorders Insomnia,
and hormones including cortisol, areRestless reduced inSyndrome,
Legs the their bed partner, asking for insomnia symptoms,
elderly. Sleep homeostasis also declines
7
Sleepwith sleep-wake patterns, other sleep related questions,
aging. breathing,
disordered
The age-related decrease in total sleep REMtimesleep
andbehavior disorder
daytime functioning, and previous treatments.13
sleep efficiency may be partially due to the reduced As in younger adults, use of the sleep diary and/or
homeostatic sleep pressure with aging.8,9 The age- structured sleep questionnaires (e.g., Insomnia Severity
related changes mentioned above are mostly relevant Index, Pittsburg Sleep Quality index) is appropriate
to older adults who are in excellent health. However, in older adults. Elderly people with significant vision
a significant percentage of older adults have multiple or hearing impairment and problems with manual
comorbidities, including osteoarthritis, cardiovascular dexterity may have difficulty with completing these
disease, pulmonary disorder, psychiatric illnesses, diagnostic methods. Objective assessments of sleep such
diabetes mellitus, gastroesophageal reflux and cancer. 10 as polysomnography and wrist actigraphy are usually
The increased use of medications along with an increase not indicated in the routine evaluation of insomnia
in prevalence of primary sleep disorders may also have but may be utilized to rule out other sleep disorders
a detrimental effect on sleep. It is therefore reasonable including sleep disordered breathing, disruptive
to say the sleep problems reported in elderly people are nocturnal movements, and circadian rhythm sleep-
usually multifactorial and are not necessarily explained wake disorders.14 The treatment of insomnia in the
by age alone. elderly population must include maintaining a regular
sleep-wake schedule, optimizing treatment of comorbid
Common age-related sleep disorders medical and psychiatric conditions, and eliminating
Insomnia medications contributing to insomnia. Several studies
There is a high prevalence of reported sleep suggest behavioral/psychological treatment should
disturbances in the elderly. Foley and colleagues be the first-line treatment for insomnia in older
reported up to 43% of older adults with complaints adults.15 Cognitive therapy of insomnia(CBTi) is a
of initiating or maintaining sleep.11 Multiple factors multicomponent process that involves cognitive and
increase the risk of developing insomnia in older behavioral techniques like stimulus control therapy,
adults. (Table 2.) For example, sleep complaints may be sleep restriction therapy, cognitive restructuring,
caused by behavioral and environmental issues. Many relaxation techniques, and sleep hygiene education.16
individuals older than 65 years are retired and may not Pharmacotherapy should be exercised with caution
feel the need to follow a regular sleep-wake schedule. In in the elderly due to reduced metabolism, as well as,
addition, people who are institutionalized may be at a drug-to-drug interactions in patients that take multiple
higher risk of sleep disturbance due to social isolation medications. Longer acting benzodiazepines should

Missouri Medicine | September/October 2020 | 117:5 | 491

 Increased Decreased
Sleep Latency Sleep efficiency
Sleep Parameter Time awake after sleep onset (WASO) Total sleep time
Number of arousals from sleep Slow wave sleep
SCienCe OF MediCine

Table 2. Causes of poor sleep in the Elderly Subjects

Physiologic Age related changes in sleep efficiency

Medical Disorders Cardiopulmonary disorders,
Arthritis,
Chronic pain syndrome,
Neurodegenerative disorders
Gastroesophageal reflux disorder
Psychiatric Disorders Depression,
Anxiety Disorder
Behavioral Excessive napping,
Use of caffeinated beverages, including alcohol
Medications Diuretics, Beta-blockers, Anti-depressants
Primary sleep disorders Insomnia,
Restless Legs Syndrome,
Sleep disordered breathing,
REM sleep behavior disorder

be avoided due to risks of daytime sedation, falls, attributed to the structural changes to the upper airway,
and confusion.17 Due to a shorter duration of action, including lengthening of soft palate and upper airway
most non-benzodiazepines (zolpidem, eszopiclone and fat pad deposition.23 Elderly people are more likely to
zaleplon) are believed to carry a lower risk of side effects. present with excessive daytime sleepiness and nocturia
However, these should be avoided in older adults with while witnessed apneas and snoring may not be
dementia and cognitive impairment.18 Other FDA reported as frequently.24, 25
approved agents include melatonin receptor agonist, Although there has been controversy about whether
such as ramelteon which has shown efficacy in older sleep disordered breathing has health consequences in
adults for sleep initiation insomnia.19 Diverse categories older adults, recent studies indicate a significant health
of antidepressants (including trazodone, tricyclic risk of sleep disordered breathing in older adults.26, 27
antidepressants, and mirtazapine) and first-generation In a six-year follow-up in a population-based cohort of
anti-histamines (diphenhydramine) have been used 394 noninstitutionalized elderly subjects (ages 70-100
for the treatment of insomnia. In the absence of an years, median 77 years, 57% men), Munoz et al. found
underlying depressive disorder, antidepressants should that severe obstructive sleep apnea (Apnea Hypopnea
be avoided in the elderly because they can also increase Index (AHI) index of greater than 30) at baseline had
the risk of falls and cause orthostatic hypotension. an increased risk of ischemic stroke in the elderly.28
Melatonin is an endogenous hormone secreted by the
Whether sleep disordered breathing increases the risk
pineal gland and has been used in people with insomnia
of hypertension in older adults remains uncertain given
in different doses and strengths. Melatonin decreases
the conflicting findings in the literature. In a cross-
subjective sleep latency in some studies but may cause
sectional analysis, sleep disordered breathing was not
headaches and drowsiness.20 Melatonin preparations are
associated with systemic hypertension in subjects age
not regulated by the FDA.
60 years or older.29 Conversely, a French study reported
Obstructive Sleep Apnea that an AHI of 30 or greater was independently
Obstructive sleep apnea (OSA) is characterized associated with incident hypertension, after three
by instability of the upper airway during sleep via years, in normotensive older adults.30 A longitudinal
recurrent pharyngeal collapse which results in reduced study of incident congestive heart failure showed
(hypopnea) or absent(apnea) airflow.21 OSA increases that each 10 unit increase in the AHI led to a 13%
with advancing age, with prevalence estimates varying increase in heart failure in men, but not in woman.31
depending on the definition used. OSA prevalence in The diagnosis of sleep apnea requires overnight sleep
older adults may be as high as 70% in men and 56% study and previously necessitated an overnight stay at
in woman as compared to the prevalence estimates of an in-lab sleep facility. The Centers for Medicare and
15% in men and 5% in women in the general adult Medicaid Services has also approved portable at home
population.22 The increase in prevalence has been sleep apnea testing (HSAT) for subjects with suspicion

492 | 117:5 | September/October 2020 | Missouri Medicine

 SCienCe OF MediCine

of sleep disordered breathing. Home sleep testing is including iron deficiency anemia, chronic renal disease
generally recommended for patients with moderate to and peripheral neuropathy. Medications including
high clinical probability of sleep apnea. Ambulatory SSRIs, tricyclic antidepressants, lithium along with
monitoring can be successfully completed in older excess caffeine intake and tobacco smoking can worsen
adults, but factors such as adequate visual acuity, symptoms in RLS patients. Restless leg syndrome is
arthritis and other functional limitations may need to common in older people, with an estimated prevalence
be addressed. of 10-35% among those over 65 years of age.37
As with younger adults, continuous positive airway The majority of people with RLS also present with
pressure (CPAP) therapy is the treatment of choice in periodic limb movements (PLMs) in sleep that are
older patients. Before instituting any specific treatment, characterized by repetitive, stereotyped movements
certain general measures are recommended including of the big toe and ankle and occasionally of the knee
weight loss, smoking cessation, avoidance of alcohol and hip. However, PLMs occur in the absence of RLS
and sedatives before bedtime, avoidance of supine sleep approximately 70% of the time. 38 This syndrome is
position and maintaining nasal patency. The major diagnosed with polysomnography by recording bursts
limiting factor for CPAP use is patient adherence: of electromyographic activity that recur at regular
approximately 40 to 50% are adherent.32 Older age periods in the affected muscles. Although PLMs may
by itself does not affect CPAP adherence.33 Adherence be asymptomatic and require no treatment, the findings
to CPAP therapy in older adults may be impaired by of PLMs in patients with unexplained insomnia may
factors such as medical and mood disorders, cognitive warrant appropriate treatment. The pathogenesis of RLS
impairment, impaired manual dexterity, nocturia, and is unclear, but appears to involve abnormalities in the
dopaminergic neural transmission.39 Iron replacement
lack of a supportive partner. The benefits of CPAP
therapy should be considered for RLS treatment
therapy are noticeable in older population, with
when serum ferritin levels are lower than 50 µg/L. If
improvement in cognition, memory, executive function,
there is no response to iron supplementation or the
sleep quality and cardiovascular function.34 For
initial ferritin is >50µg/L, RLS is usually treated with
Medicare to cover CPAP therapy long-term, the patient
dopaminergic agents such as ropinirole or pramipexole.
must use CPAP for a minimum of four hours a night
Patients should be warned about side effects including
on 70% of the nights for at least one month during sleep attacks and compulsive behaviors. In some cases,
the initial three-month trial. In addition, they require augmentation can occur that leads to reemergence and
a face-to-face encounter with the ordering physician worsening of RLS symptoms. Alpha-2-delta calcium
to document clinical response at sometime between channel ligands such as gabapentin, gabapentin
months one and three. Individuals who have failed enacarbil, and pregabalin are also effective therapies for
or refused CPAP therapy for obstructive sleep apnea RLS with data showing decreased augmentation with
may be considered for oral appliances. These devices pregabalin.40 Benzodiazepines and opioids may be used
are effective in treating snoring and mild to moderate in refractory cases but caution is warranted while using
obstructive sleep apnea but may not be appropriate in these medications in the elderly population.
older adults who are edentulous. Common side effects
include dry mouth, increase salivation, tooth soreness rapid eye movement sleep disorder
and temporomandibular joint discomfort. As with Rapid eye movement sleep disorder (RBD) is
younger adults, upper airway surgery is not particularly a parasomnia that occurs during REM sleep and is
effective for older patients and may be associated with characterized by dream enacting behavior. Affected
especially high morbidity in the elderly.35 people may display a variety of movements, which in
extreme cases can be harmful to the patient or bed
sleep-related movement disorders partner. These behaviors/movements can include
Restless legs syndrome, also known as Willis- talking, shouting, thrashing limbs, punching, while
Ekbom disease, is characterized by an urge to move remaining in REM sleep. RBD is most prevalent among
the legs often accompanied by abnormal leg sensation, older adult males.41 Although the etiology of RBD
resulting in sleep initiation and/or sleep maintenance is unclear, acute onset of RBD has been associated
problems.36 Restless legs syndrome (RLS) may be with the use of tricyclic antidepressants, fluoxetine,
idiopathic or secondary to other medical conditions monoamine oxidase inhibitors, and withdrawal

Missouri Medicine | September/October 2020 | 117:5 | 493

SCienCe OF MediCine

from alcohol or sedatives.42 Chronic RBD has been sleep and dementia
associated with neurodegenerative disorders such Sleep disturbances are common (25-40%) in
as Parkinson’s disease, Lewy body dementia, and patients with Alzheimer’s dementia.46 Patients with
multiple system atrophy. Interestingly, symptoms of neuro-degenerative disorders, including Lewy body
REM sleep behavior disorder may precede a diagnosis dementia (LBD) or Parkinson’s disease (PD) may have
of Parkinson’s disease for years.43 RBD is diagnosed sleep disorders including REM sleep behavior disorder
with polysomnogram to detect loss of muscle atonia (RBD). Sleep disordered breathing is the most common
during REM sleep in the setting of proper clinical sleep disorder in individuals with vascular dementia
context. Patient education, including removing while patients with Alzheimer’s dementia present more
potentially hazardous objects from the bedroom and commonly with symptoms of insomnia and excessive
placing the mattress on the floor to prevent falling daytime napping.47 The polysomnographic findings
from the bed is important to prevent sleep-related in patients with Alzheimer’s disease include a decrease
injury. RBD is often treated with clonazepam, a long- in sleep efficiency, increase in N1 sleep, increase in
acting benzodiazepine, which is shown to reduce or awakening frequency, and a reduction in sleep spindles
eliminate abnormal motor behavior in approximately and K complexes.48 Individuals with dementia are
90% of RBD patients.44 Melatonin is an alternative
also at risk for irregular sleep-wake rhythm disorder
therapy and is usually better tolerated in the elderly
(ISWRD) where the person sleeps in fragmented
population and therefore may be used as a first-line
episodes during the day and night. Pharmacological
agent in this group.45
agents for the treatment of dementia may also disrupt
Circadian rhythm sleep-wake disorders sleep. Individuals taking acetylcholinesterase inhibitors
Circadian rhythm sleep-wake disorders to slow down the cognitive decline in Alzheimer’s
(CRSWD) occur when the timing of sleep is dementia may lead to increased nighttime arousals and
disrupted due to an altered circadian rhythm or nightmares.49 Behavioral interventions including a daily
mismatch between an individual’s circadian rhythm consistent routine for bed and wake times should be
and required sleep-wake schedule. The sleep-wake instituted. Naps may be planned but should be brief
cycle is controlled by the suprachiasmatic nucleus and consistently done at the same time every day. Bright
(SCN) in the hypothalamus. This brain region light therapy has been shown to increase sleep efficiency
controls the internal circadian pacemaker, which is and total sleep time in individuals with dementia.50
synchronized to the hour of the day by both external
cues and internal cues. Light is the most important Conclusion
external queue while the core body temperature and In conclusion, there are changes to sleep
melatonin are the internal cues. Circadian rhythms architecture throughout the lifespan that are considered
become weaker and less responsive to the external normal. Older people have difficulty in falling asleep
stimuli with advancing age. Advance sleep-wake phase and staying asleep due to frequent arousals. It is
schedule (ASWPS) is the most common circadian important to know how sleep patterns change as we
rhythm sleep-wake disorder in older adults. Elderly age and, at the same time, to recognize primary sleep
people with ASWPS tend to become sleepy early in disorders among the elderly people. Careful assessment
the evening (typically between 1900 and 2000 h) of sleep including a comprehensive sleep history, and
and wake up early in the morning (typically around relevant testing, should be conducted to evaluate the
0300 to 0400 h). Many of these adults feel pressure patient’s complaints. Treatment should address both the
from societal norms to stay up later in the evening, primary sleep problem and any comorbidities thereby
despite being sleepy and despite continuing to wake optimizing the chance for improvement in quality of
up early in the morning. This can lead to limited life and functioning in older adults.
sleep resulting in daytime sleepiness. ASWPS can
easily be misdiagnosed as insomnia and it’s important
references
to differentiate between the two diagnoses because 1. Centers for Disease Control and Prevention. The state of aging and
the treatment approach differs. Circadian rhythm health in America 2013. Atlanta (GA): Centers for Disease Control and
disorders are treated with bright light therapy where Prevention;2013
2. Vitello MV. Sleep in normal aging. Sleep Med Clinic. 2006; 1:171-176
the patient is exposed to light at specific times which 3. Inouye SK, Studenski S, Tinetti ME et al. Geriatric syndromes: clinical,
helps to realign the sleep-wake schedule. research, and policy implications of a core geriatric concept. J Am Geriatr

494 | 117:5 | September/October 2020 | Missouri Medicine

 SCienCe OF MediCine

going Soc 2007;55(5):780-791 29. Haas DC, Foster GL, Nieto FJ et al. Age-dependent associations
4. Cooke J, Anconi-Israel S. normal and abnormal sleep in the elderly. Hand between sleep-disordered breathing and hypertension importance of
Clin. Neurol. 2011; 98:653-665 discriminating between systolic/diastolic hypertension and isolated
5. Ohayon MM, Carskadon MA. Guilleminault D et al. meta-analysis systolic hypertension in the sleep heart health study. Circulation
of quantitative sleep parameters from childhood to old age in healthy 2005;111(5):614-21.
individuals: developing normative sleep values across the human lifespan. 30. Guillot M, Sforza E, Achour-Crawford E et al. Association between
Sleep 2004; 27(7): 1255 – 1273 severe obstructive sleep apnea and incidental arterial hypertension in the
6. Edwards B, O’ Driscoll D, Ali A et al. aging and sleep: physiology and older people population. Sleep Med 2013;14(9):838-42.
pathophysiology. Semin Respir Crit Care Med 2010;31(5): 618-633 31. Gottlieb DJ, Yenokyan G, Newman AB et al. prospective study of
7. Duffy JF, Zitting KM, Chinoy ED. Aging and circadian rhythms. Sleep obstructive sleep apnea and incident coronary heart disease and heart failure:
Med Clin 2015;10(4):423-34. the sleep heart health study. Circulation 2010; 122(4):352-60.
8. Dijk DJ, Duffy JF, Riel E et al. Ageing and the circadian and homeostatic 32. Sawyer AM, Gooneratne NS, Marcus CL et al. A systematic review of
regulation of human sleep during forced desynchrony of rest, melatonin and CPAP adherence across age groups: clinical and empiric insights for developing
temperature rhythms. J Physiol 1999;516(Pt 2):611-27 CPAP adherence interventions. Sleep Med Rev. 2011;15(6):343-56.
9. Dijk DJ, Greoger JA, Stanley N et al. Age-related reduction in daytime 33. Russo-Magno P, O’Brien A, Panciera T et al. Compliance with CPAP
sleep propensity and nocturnal slow-wave sleep. Sleep 2010;33(2):211-23. therapy in older men with obstructive sleep apnea. J AM Geriatr Soc.
10. Fillenbaum GG, Pieper CF, Cohen HJ et al. Comorbidities of five 2001;49(9):1205-11.
chronic health conditions in elderly community residents: determinants and 34. Weaver TE, Chasens ER. Continuous positive airway pressure treatment
impact on mortality. J Gerontol A Biol Sci Med Sci 2000;55(2):M84-9. for sleep apnea in older adults. Sleep Med Rev. 2007;11(2):99-111.
11. Foley DJ, Monjan AA, Brown SL et al. Sleep complaints among 35. Malhotra A. White D. Obstructive Sleep Apnoea. Lancet 2002;
elderly persons: an epidemiologic study of three communities. Sleep 360:237-45.
1995;18(6):425-32 36. Allen RP, Picchietti DL, Garcia-Borreguero D et al. restless leg
12. Benca R, Ancoli-Israel S, Moldofsky H. Special considerations in syndrome/Willis-Ekbom disease diagnostic criteria: updated international
insomnia diagnosis and management: depressed, elderly, and chronic pain restless legs syndrome study group (IRLSSG) consensus criteria- history,
populations. J Clin Psychiatry. 2004;65(8):26-35. rationale, description, and significance. Sleep Med 2014; 15:860-73.
13. Schutte-Rodin S, Broch L, Buysse D et al. Clinical guideline for the 37. Milligan SA, Chesson AL. Restless legs syndrome in the older adult:
evaluation and management of chronic insomnia in adults. J Clin Sleep
diagnosis and management: Drugs aging 2002;19:741-51.
Med 2008;4(5):487-504.
38. Vaz Fragoso CA, Gill TM. Sleep complaints in community-living
14. Littner M, Hirshkowitz M, Kramer M et al. Practice parameters for using
older persons: a multifactorial geriatric syndrome. J Am Geriatr Soc
polysomnography to evaluate insomnia: an update. Sleep 2003; 26(6): 754 – 60.
2007;55(11):1853-66.
15. Morgenthaler T, Kramer M, Alessi C, et al: Practice parameters for the
39. Glasauer FE. Restless Legs Syndrome. Spinal cord 2001; 39:125-33.
psychological and behavioral treatment of insomnia: an update. An American
40. Allen RP, Chen C, Garcia-Borreguero D et al. comparison of
Academy of Sleep Medicine report. Sleep 2006 29 (11):1415-1419
pregabalin with pramipexole for restless leg syndrome. N Engl J Med.
16. Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and behavioral
treatment of insomnia: update of the recent evidence (1998-2004). Sleep 2014;370(7):621-31
2006;29(11):1398-414. 41. Oksenberg A, Radwan H, Arons E et al. Rapid Eye Movement (REM)
17. Tannenbaum C. Inappropriate benzodiazepine use in elderly patients sleep behavior sleep disorder: a sleep disturbance affecting mainly older
and its reduction. J Psychiatry Neurosci 2015;40(3): E27-8 men. Isr J Psychiatry Relat Sci 2002; 39:28-35
18. American Geriatrics Society Beers Criteria Update Expert Panel. J Am 42. Sforza E, Krieger J, Petiau C. REM sleep behavior: clinical and physio-
Geriatr Soc 2015;63(11):2227-46 pathological findings. Sleep Med Rev 1997;1: 57-69
19. Roth T, Seiden D, Sainati S et al. Effects of ramelteon on patient 43. Lai YY, Siegel JM. Physiological and anatomical link between
reported sleep latency in older adults with chronic insomnia. Sleep Med. Parkinson- like disease and REM sleep behavior disorder. Mol Neurobiol
2006 Jun;7(4):312-18. 2003; 27:137-52
20. Buscemi N, Vandermeer B, Hooton N et al. The efficacy and safety of 44. Schenck CH, Mahowald MW. Polysomnographic, neurologic,
exogenous melatonin for primary sleep disorders: a meta-analysis. J Gen psychiatric and clinical outcome report on 70 consecutive cases with the
Intern Med 2005;20(12):1151-58 REM sleep behavior disorder (RBD): sustained clonazepam efficacy in
21. McNicholas W. diagnosis of obstructive sleep apnea in adults. Proc Am 89.5% of 57 treated patients. Cleve Clin J Med 1990;57: S10-24
Thorac Soc. 2008; 5:154-60. 45. McGrane IR, Leung JG, St Louis EK et al. melatonin therapy for
22. Bloom HG, Ahmed I, Alessi CA et al. Evidence-based recommendations REM sleep behavior disorder: a critical review of evidence. Sleep Med.
for the assessment and management of sleep disorders in older adults. J Am 2015;16(1):19-26
Geriatr Soc 2009;57(5):761-89. 46. Guarnieri B, Adorni F, Musicoo M et al. prevalence of sleep
23. Bilwise DL. Normal aging. In: Kryger MH, Roth T, Dement WC. disturbances in mild cognitive impairment and dementing disorders: a
Principals and practice of sleep medicine. 6th edition. Philadelphia: multicenter Italian clinical cross-sectional study on 431 patients. Dement
Elsevier;2016. P. 25-38. Geriatr Cogn Disord 2012; 33:50-58
24. Endeshaw Y. Clinical characteristics of obstructive sleep apnea in 47. Zhou QP, Jung L, Richards KC. The management of sleep and
community dwelling older adults. J Am Geriatric Soc 2006;54(11):1740-4. circadian disturbance in patients with dementia. Curr Neurol Neurosci Res.
25. Phillips B. O Philadelphia. Obstructive sleep apnea in the elderly. 2012;12(20):193-204
In: Kryger MH, Roth T, Dement WC. Principles and practices of sleep 48. Vitiello MV, Bliwise DL, Prinz PN. Neurology 1992; 42:83-93
medicine. 6thd edition. Philadelphia: Elsevier;2016. p. 1496-502 49. Dauvilliers Y. insomnia in patients with neurodegenerative conditions.
26. Strand LB, Carnethon M, Biggs ML et al. sleep disturbances and Sleep Med. 2007;8: S27-34
glucose metabolism in older adults: the cardiovascular health study. Diabetes 50. Sloane PD, Williams CS, Mitchell CM et al. high-intensity
Care 2015;38(11):2050-58. environmental light in dementia: effects on sleep and activity. J Am Geraitr
27. Lavie L, Lavie P. Ischemic preconditioning as a possible explanation Soc. 2007;55(10):1524-33
for the age decline relative mortality in sleep apnea. Med Hypothesis
2006;66(6):1069-73.
28. Munoz R, Duran-Contolla J, Martinez-Villa E et al. Severe sleep apnea
disclosure
and risk of ischemic stroke in the elderly. Stroke. 2006; 37:2317-21. None reported. MM

Missouri Medicine | September/October 2020 | 117:5 | 495