Aging has an impact on sleep, and as our population becomes older, you can expect more geriatric patients coming to your office for evaluation and treatment of sleep disorders.
Sleep disorders often occur in conjunction with other health related problems that are more common among older people, such as cardiovascular disease, cognitive decline, musculoskeletal problems and renal and hepatic decline.
Retired individuals may experience circadian rhythm disorders and present reporting diminished ability to get refreshing sleep. Many older patients take naps on and off throughout the day and then cannot sleep at night. Encourage them to keep a regular bedtime and wake schedule to help maintain their internal clock. Discourage daytime napping, or suggest they limit naps to one 30-minute nap per day.
Geriatric patients have more frequent night-time awakenings from sleep. The cause is still being studied, but it may be due to a structural decline in the hypothalamic suprachiasmatic nucleus, which results in impaired melatonin release.
As many as 50% of older people report insomnia, typically accompanied by anxiety and depression related to advancing age, worsening medical conditions, loss of a partner and decreased income. Patients may experience difficulties with falling asleep, maintaining sleep and waking too early.
For patients with insomnia, review sleep hygiene measures at every visit. Sleep aids can be used, but start with the lowest dose first. Monitor patients carefully and advise them that they may be at increased risk for falls. Try sedating antidepressants, such as trazodone and amitriptyline, first. Melatonin receptor agonists can also be helpful.
Sleep disordered breathing, such as obstructive sleep apnea and central sleep apnea, are also common in this population. Ruling these conditions out with polysomnogram is important as health issues and depression can worsen if left untreated. CPAP therapy and/or dental appliances are the best treatments.
Restless leg syndrome (RLS) and periodic limb movements (PLMD) of sleep increase in prevalence as patients age and may affect as much as 60% of the geriatric population. There is a genetic component to both disorders, so ask patients about family history.
Iron deficiency may also occur with RLS and PLMD, so check ferritin levels a patient has either disorder.
Treatment includes GABA agonists, dopamine agonists, opiates and benzodiazepines. Supplement with iron if needed and try to keep ferritin levels at or above 45 ug/L for best results.
Quality of life is the most important goal. Encourage geriatric patients who report sleep problems to keep a regular schedule, exercise and participate in social activities on a regular basis.
Specifically inquire about sleep in older patients, as many will not automatically consider sleep issues to be problem. Many feel it is normal for someone of advanced age. Remind patients that even though sleep disorders occur more frequently with advancing age, it doesn’t mean these issues are normal or can’t be treated.
Sharon M. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.