Sleep disorders in elderly patients are common, treatable

Sleep disorders become more common with increasing age, but effective behavioral and pharmacological therapies are available, sleep experts said at the annual meeting of the American Association for Geriatric Psychiatry. Most older adult are not being treated for their insomnia, and most older adults won’t get a diagnosis of insomnia, despite the high prevalence of the disorder in this age group, the medical director of the Sleep Disorders Center at Northeastern Memorial Hospital in Chicago said.

There are several age-related changes in sleep architecture. The number of awakenings during sleep increases, especially in the early morning. The amount of light sleep increases and the amounts of deep sleep and REGM sleep decreases. Two major mechanisms regulate sleep in humans: the homeostatic drive and the circadian rhythms. With age, the amplitude of circadian rhythms decreases, while the variability of circadian rhythms increases.There’s also a very noticeable advance in the phase of circadian rhythms. Severe disruptions of the sleep/wake cycle often occur in older adults with dementia and patients in nursing homes. The homeostatic drive for sleep depends on accumulating enough hours of wakefulness to trigger sleep, and this drive is reset during sleep.

It’s important to understand these sleep mechanisms when treating sleep disorders. There is not a thing you can do to make yourself go to sleep… What you can do is arrange the circumstances and timing of our wakefulness in a way that makes the involuntary process of sleep more likely. To understand a patient’s sleep habits, behavioral therapists start by asking about average time in bed, average rise time, total time in bed, time to fall asleep, amount of wakefulness during the night, and total wake time. For most individuals with insomnia, there is a discrepancy between the amount of sleep that they get and the amount of time they spend in bed.

A colleague tested the effect of these changes in sleep behavior on sleep quality in a small study of 13 patients who made these changes, compared with 12 subjects who received basic sleep information. Those in the active treatment group had a significant improvement in sleep quality, while those in the control group had no change. Also, those in the active treatment group had reduced sleep latency and waking after sleep onset, while controls did not.

Medications for acute and chronic insomnia include benzodiazepine receptor agonists, melatonin receptor agonists, and antidepressants. In 2005, a National Institutes of Health state-of-the-science panel noted that hypnotics are efficacious for short-term treatment of insomnia. But with the exception of eszopiclone, these drugs have not been studied long-term.

Zaleplon (Sonata), zolpidem (AMbien), and eszopiclone (Lunesta)-benzodiazepine receptor agonists — are all indicated for the treatment of insomnia. These drugs differ (from benzodiazepines) mainly in terms of their pharmacokinetics. One note of caution: Benzodiazepines and related drugs have been shown to increase the risk of falling. Ramelteon, a short-acting melonin receptor agonist, takes advantage of the circadian system that secretes melatonin at night. Ramelteon has been shown to reduce sleep latency and increase total sleep time in younger and older adults. The drug appears to be less effective for wakefulness after sleep onset. Caution should be used with this drug in patients also taking fluxovoxamine, which inhibits some of the enzymes that degrade ramelteon. No evidence-based standards of practice or treatment algorithms exist for treating insomnia in older adults, but we think that it makes sense to always use behavioral approaches before, or in combination with medication.–Charles C. Chante, MD, Philippine Star