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Sleep problems
Introduction
Sleep-related disorders are common in the general adult population, with 50-70 million Americans affected by chronic sleep disorders.1,2 A common misconception among patients and clinicians is that these disorders are a normal and expected phenomenon of aging. Given the high prevalence, complexity, and health implications associated with sleep disorders in older adults, increasing attention is now being focused on this topic as a multifactorial geriatric syndrome.1,3 While older adults still require as much sleep as younger adults, normal changes in sleep and circadian rhythm with age lead to increased difficulty falling asleep, poorer sleep quality, and more time awake during the night.1,2,3 Beyond normal physiological alternations, current research suggests that sleep complaints in older adults are due to multiple factors, including poor sleep hygiene, age-related increase in prevalence of chronic medical conditions, and psychosocial changes that accompany aging.1,2,3,4 Lifestyle changes common in old age, such as retirement, reduced mobility, and reduced social interaction, can all be sources of sleep disruption.4
The most common primary sleep disorders in older adults are insomnia, obstructive sleep apnea, restless leg syndrome, and excessive daytime sleepiness.1,2,4 As many as 57% of older adults complain of significant sleep disruption, 45% have periodic limb movements during sleep, 29% suffer from insomnia, 24% have obstructive sleep apnea, 20% experience excessive daytime sleepiness, 19% complain of early morning awakening, and 12% have symptoms of restless leg syndrome.1 A strong bidirectional relationship has been found between sleep disorders and multiple comorbid medical conditions. Individuals with cardiovascular disease, hypertension, cerebrovascular disease, dementia, Parkinson’s disease, and depression are more likely to suffer from sleep disturbance and poor health outcomes. Patients with symptoms that tend to exacerbate in the evening, such as those with chronic pain, paresthesia, nighttime cough and dyspnea, gastroesophageal reflux, and nocturia, may experience increased difficulty with sleep.1,2
Prescription medications also frequently interfere with sleep if taken in the evening, including diuretics, stimulating agents such as bronchodilators, anti-Parkinsonian agents, and antihypertensives. Sedating medications taken during the day, such as antihistamines and anticholinergics, will contribute to daytime drowsiness and further disrupt the sleep-wake cycle.1 Environmental factors play a role as well. Up to 60% of patients report experiencing impaired sleep while in the hospital. For older adults who already suffer from sleep disturbance, hospitalization can cause these conditions to be more acute. Patients in hospitals and long-term care settings are often exposed to noise and light interruptions during the night, which interferes with circadian rhythms. Older adults who are institutionalized also spend extended periods of time in bed and tend to be physically inactive during the day, which can increase restlessness at night.1,2
Interprofessional Assessment and Collaborative Interventions
Members of the health care team should thoroughly assess patients complaining of issues with sleep to identify underlying etiology and target interventions accordingly. Many clinicians are unaware of the influence that sleep disorders have over patient morbidity and mortality. As a result, these issues are often under-investigated or even ignored.1 Nurses can assist in completing a thorough sleep history to determine patients’ usual patterns and detect presence of sleep disorders using validated tools such as the Pittsburgh Sleep Quality Index (PSQI) at the point of care.2,4 Clinicians are encouraged to enquire about sleep on a regular basis, beginning with a baseline assessment and then semi-annually for returning patients. Patients’ partners and family members can help provide clinicians with information about the patient’s sleep patterns and any concerns regarding nighttime behaviors.1
Clinicians are encouraged to begin treatment for sleep disturbance by addressing habits, behaviors, and environmental factors affecting patients’ sleep. Registered nurses and nurse practitioners can provide sleep hygiene education, informing patients about common habits or practices that interfere with sleep and how to implement strategies to avoid them.1,4 In turn, nurses can help protect patients’ sleep and improve sleep quality by reducing noise, light, and patient care activities at night.2 Providers should consult with sleep specialists (physicians and psychologists) surrounding behavioral treatments and non-pharmacologic approaches that may be effective for each patient. Relaxation therapy, structured sleep schedules, sleep hygiene education, cognitive behavioral therapy, exercise and physical activity, and light therapy have all been proven effective for treatment in older adults.1,2,4
In general, use of benzodiazepines in treatment of sleep disturbance in older adults is not recommended.4 However, non-benzodiazepines and melatonin receptor agonists may be used to aid older adults in falling and staying asleep. If prescribers and pharmacists jointly determine the need for medication, the most short-acting drug should be selected in the lowest dose and in conjunction with an appropriate behavioral intervention.1,2,3,4 It is essential that primary and acute care providers consult with pharmacists in reviewing all of patient’s medications when adding a pharmacological intervention for sleep to balance management of chronic illnesses while avoiding polypharmacy.1,2 Primary and acute care providers may also refer patients to a sleep specialist for a polysomnography evaluation to confirm presence and severity of sleep disorders, especially in cases of obstructive sleep apnea that must be immediately treated.1
Interprofessional contacts for this topic:
Primary care providers
Acute care providers
Registered nurses
Pharmacists
Sleep specialists (MDs, psychologists)
Link to the following evidence-based protocols:
Age-related changes
Iatrogenesis
Medication
Sleep
References
1Bloom, H. G., Ahmed, I., Alessi, C. A., Ancoli‐Israel, S., Buysse, D. J., Kryger, M. H., ... & Zee, P. C. (2009). Evidence‐based recommendations for the assessment and management of sleep disorders in older persons. Journal of the American Geriatrics Society, 57(5), 761-789.
2Chasens, E. R., & Umlauf, M. G. (2012). Excessive sleepiness. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker (Eds.), Evidence-based geriatric nursing protocols for best practice (4th ed., pp. 74-88). New York, NY: Springer Publishing Company.
3Vaz Fragoso, C. A., & Gill, T. M. (2007). Sleep complaints in community‐living older persons: A multifactorial geriatric syndrome. Journal of the American Geriatrics Society, 55(11), 1853-1866.
4Wennberg, A. M., Canham, S. L., Smith, M. T., & Spira, A. P. (2013). Optimizing sleep in older adults: treating insomnia. Maturitas, 76(3), 247-252.