Sleep and aging: 1. Sleep disorders commonly found in older people

Sociodemographic and health correlates of sleep quality and duration among very old Chinese

STUDY OBJECTIVES

To examine factors associated with self-reported sleep quality and duration among very old adults in China.

DESIGN

Cross-sectional analysis of the 2005 wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS).

SETTING

In-home interview with older adults in 22 provinces in mainland China.

PARTICIPANTS

A total of 15,638 individuals aged 65 and older (5,047 aged 65-79, 3870 aged 80-89, 3927 aged 90-99, and 2794 aged 100 and older, including 6688 men and 8950 women).

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Two self-reported sleep questions together with numerous sociodemographic and health status measures were used in this study. Sixty-five per cent of Chinese elders reported good quality of sleep. The average number of self-reported hours of sleep was 7.5 (SD 1.9), with 13.1%, 16.2%, 18.0%, 28.0%, 9.2%, and 15.5% reporting < or = 5, 6, 7, 8, 9, and > or =10 hours, respectively (weighted). Multivariate analyses showed that male gender, rural residence, Han ethnicity, higher socioeconomic status, and good health conditions were positively associated with good quality of sleep. All other factors being equal, octogenarians, nonagenarians, and centenarians were more likely to have good sleep quality than the young elders aged 65-79. Elders with poorer health status or older age were more likely to have either relatively shorter (< or = 6 h) or longer (> or = 10 h) sleep duration. Married elders were more likely to have an average duration between these two values. Except for some geographic variations, associations between all other factors and sleep duration were weak compared to the effects of health.

CONCLUSIONS

Age and health conditions are the two most important factors associated with self-reported sleep quality and duration. Good quality of sleep among long-lived old adults may have some implications for achieving healthy longevity.

Sleep-related problems and use of hypnotics in inpatients of acute hospital wards

OBJECTIVE

Although sleep disorders are highly prevalent among patients with physical disorders, only limited information is available about the actual status of sleep-related problems in inpatients of acute hospital wards. We conducted a multicenter cross-sectional observational survey investigating the prevalence of sleep disorders and use of hypnotic-sedative drugs among inpatients of acute wards in 44 general hospitals in Japan.

METHOD

Questionnaire-, actigraph- and observation-based sleep evaluations were simultaneously performed in 557 adult inpatients [mean age 72.8 + or - 12.8 (S.D.) years] of acute wards during a one-month period in July 2007.

RESULTS

Of the 421 patients with data available, 22.3% had at least one of the following sleep disorders: sleep apnea syndrome, restless legs syndrome, periodic limb movement disorder and nocturnal behavior disorder. Similarly, 62.7% had insomnia, 6.9% had severe daytime sleepiness and 12.8% had other sleep-related symptoms. Only 13.8% were free of any sleep-related problem. Although 33.7% of insomnia patients were taking hypnotic-sedative drugs, 65.2% of them complained of residual insomnia symptoms.

CONCLUSION

The findings obtained in this study have revealed the remarkably high prevalence of sleep-related problems experienced by inpatients of acute hospital wards in Japan. Proper diagnosis of sleep disorders should be made among patients with physical disorders.

Preliminary results on the effect of sensor position on unobtrusive rollover detection for sleep monitoring in smart homes

Older adults experience increased sleep movement disorders and sleep fragmentation, and these are associated with serious health consequences such as falls. Monitoring sleep fragmentation and restlessness in older adults can reveal information about their daily and long-term health status. Long-term home monitoring is only realistic within the contact of unobtrusive, non-contact sensors. This paper presents exploratory work using the pressure sensor array as an instrument for rollover detection. The sensor output is used to calculate a center of gravity signal, from which five features are extracted. These features are used in a decision tree to classify detected movements in two categories; rollovers and other movements. Rollovers were detected with a sensitivity and specificity of 82% and 100% respectively, and a Mathew's correlation coefficient of 0.86 when data from all sensor positions were included. Intrapositional and interpositional effects of movements on sensors placed throughout the bed are described.

Simulated central apnea detection using the pressure variance

This paper presents use of an unobtrusive pressure sensor array for simulated central apnea detection. Data was collected from seven volunteers who performed a series of regular breathing and breath holding exercises to simulate central apneas. Results of the feature extraction from the breathing signals show that breathing events may be differentiated with epoch based variance calculations. Two approaches were considered: the single sensor approach and the multisensor vote approach. The multisensor vote approach can decrease false positives and increase the value of Matthew's Correlation Coefficient. The effect of lying position on correct classification was investigated by modifying the multisensor vote approach to reduce false positives segments caused by the balistocardiogram signal and as such increase sensitivity while maintaining a low false positive rate. Intersubject classification results had low variability in both approaches.

Sleep patterns, sleep disturbances and sleepiness in retired Iranian elders

OBJECTIVES

Complaints of sleep disturbance increase with age and many studies have reported on the relationship of sleep problems to the greater use of health services, physical and mental morbidity, functional decline, and all causes of mortality. This study aimed to examine sleep patterns and sleep disturbances in Iranian elders and correlate their sleep quality to their health status.

METHODS

Four hundred men and women, aged 60 years or older, were interviewed by trained interviewers regarding their physical and mental health status. The Pittsburgh Sleep Quality Index, the Epworth Sleepiness Scale (ESS), and a General Health Questionnaire (GHQ) were then administered to each participant. The data gathered were analyzed using chi(2)-test, t-test, and one-way analysis of variance and logistic regression.

RESULTS

The results indicated that the majority of participants (82.6%) suffered from poor sleep quality and approximately one-third (29.2%) experienced sleepiness during the daytime. Difficulty falling asleep (p < or = 0.001) and maintaining sleep (p < or = 0.01) and the feeling of being too hot at night (p < or = 0.005) were significantly more prevalent in women, but men suffered more from leg twitching (p < or = 0.01). Being female (OR = 2.52), and having GHQ scores of more than 11 (OR = 4.14) increased the risk of poor sleep quality considerably.

CONCLUSION

Promoting sleep hygiene education of elders in primary health care services are recommended.

The association of sleep duration and type 2 diabetes in Korean male adults with abdominal obesity: the Korean National Health and Nutrition Examination Survey 2005

We used data of 1652 male adults aged 20-60 years from KNHANES III. Short sleep duration was significantly associated with an increased prevalence of type 2 diabetes in Korean male adults without abdominal obesity (OR in sleep duration of <or=5 compared to 7h/day: 2.40 [95% CI, 1.18-4.91]).

[Sleep disorders in the elderly]

BACKGROUND

Sleep disorders are common in the elderly, and may lead to substantially impaired quality of life. Many of these disorders are not diagnosed or treated. This article covers treatment options and characteristics of common sleep disorders in the elderly.

MATERIAL AND METHODS

The article is based on the authors' own research and clinical experience, and on articles identified through non-systematic searches in Pubmed.

RESULTS

Many somatic and psychological complaints are associated with sleep disorders; depression is the most common comorbid diagnosis.

INTERPRETATION

A thorough assessment of the patient's sleep pattern is crucial before treatment is instigated. Pharmacological intervention is the most common treatment, but serious side effects are common and there is a high risk of addiction. Effective non-pharmacological interventions are available, also for the elderly.

Epilepsy in later life

Epilepsy is most likely to develop in later life. The burden of this disorder on health-care resources will rise further as the world's population continues to age. Making a secure diagnosis can be challenging because the clinical manifestations of seizures and the differential diagnoses and causes of epilepsy can be different in older individuals compared with younger individuals. Obtaining a reliable account of the events for accurate assessment is particularly important in guiding the appropriate choice and interpretation of investigations to arrive at the correct diagnosis. In older age, unique pharmacokinetic and pharmacodynamic changes occur. The use and selection of antiepileptic drugs is often further complicated by the presence of comorbidities, polypharmacy, and concomitant functional impairment, but there is a paucity of high-level clinical evidence on the effects of these factors as well as on the choice of treatment in the elderly. A comprehensive model of care should combine expertise in the diagnosis and treatment of epilepsy with effective assessment and management of the psychosocial effects to improve the prognosis in this vulnerable and poorly studied group of patients.

Undiagnosed sleep-related breathing disorders are associated with focal brainstem atrophy in the elderly

BACKGROUND

Sleep-related breathing disorders (SRBDs) affect as many as 40% of elderly people. The association of SRBDs with structural brain abnormalities remains unclear. In this observational study, we evaluated gray matter changes in the brain associated with sleep abnormalities in volunteers and their relationship with the severity of SRBDs.

METHODS

One hundred fifty two healthy subjects aged 66.0 +/- 0.6 years-old underwent tridimensional brain MRI and nocturnal polygraphic recording during which apnea/hypopnea index (AHI) and the oxyhemoglobin desaturation index (ODI) were measured. Using voxel-based morphometry, we investigated the presence of gray matter abnormalities in association with AHI and ODI.

FINDINGS

Seventy-six subjects (50%) had SRBDs defined by an AHI > or = to 15 and 25 subjects (16%) SRBDs defined by an ODI > or = 15, in the absence of systematic excessive daytime sleepiness. A significant symmetrical loss of gray matter in the intermediate reticular zone of the bulbopontine area was found to correlate with both AHI and ODI (P < 0.05 corrected for multiple comparisons for cluster significance).

INTERPRETATION

This gray matter volume decrease in brain regions involved in breathing/autonomic functions, as well as their correlation with the severity of the disorder, suggests a pathophysiological link between structural changes and SRBDs.

Usual sleep duration and cognitive function in older adults in Spain

The few studies that have examined the association between usual sleep duration and cognitive function have shown conflicting results. This cross-sectional study examined the association between sleep duration and cognitive function among 3212 people, representative of the non-institutionalized population aged 60 years and over in Spain. Sleep duration was self-reported, and cognitive function was measured with the Mini-Examen Cognoscitivo (MEC), a version of the Mini-Mental State Examination that has been validated in Spain. Linear regression, with adjustment for the main confounders, was used to obtain mean differences in the MEC between the categories of sleep duration (<or=5, 6, 7, 8, 9, 10, >or=11 h day(-1)). The MEC score decreased progressively (became worse) across sleep categories from 7 to >or=11 h (P for linear trend <0.001). People who slept for >or=11 h had a significantly lower MEC score than those who slept for 7 h (mean difference -1.48; 95% confidence interval -2.12 to -0.85). This difference in the MEC was similar to that observed for a 10-year increase in age. The results did not vary significantly by sex (P for interaction >0.05). No association was observed between short sleep duration (<7 h) and cognitive function. We conclude that long sleep duration is associated with poorer cognitive function in older adults from the general population.

Associations between craniofacial morphology, head posture, and cervical vertebral body fusions in men with sleep apnea

INTRODUCTION

The aim of this study was to analyze craniofacial profiles and head posture in patients with obstructive sleep apnea (OSA) subgrouped according to cervical column morphology.

METHODS

Seventy-four white men aged 27 to 65 years (mean, 49.0 years) diagnosed with OSA in sleep studies by using overnight polysomnography were included. Only patients with apnea-hypopnea index scores between 5.1 and 92.7 (mean, 36.4) were included. Lateral profile radiographs in standardized head posture were taken, and cephalometric analyses of sagittal and vertical jaw relationships were made. The patients were divided into 4 groups according to fusion in the cervical vertebrae: group I, no fusions (42 subjects); group II, fusion of cervical vertebrae 2 and 3 (15 subjects); group III, occipitalization (10 subjects); and group IV, block fusion (11 subjects). Mean differences of craniofacial dimensions between the groups were assessed by unpaired t tests.

RESULTS

No significant differences were seen between groups I and III. Between groups I and II, significant differences were seen in jaw relationship (P < 0.05). Between groups I and IV, anterior face height and mandibular length deviated significantly. No significant differences were seen in head posture.

CONCLUSIONS

OSA patients with block fusions in the cervical vertebrae and fusion of 2 vertebrae differed significantly in craniofacial profile from other OSA patients.

Evidence-based recommendations for the assessment and management of sleep disorders in older persons

Sleep-related disorders are most prevalent in the older adult population. A high prevalence of medical and psychosocial comorbidities and the frequent use of multiple medications, rather than aging per se, are major reasons for this. A major concern, often underappreciated and underaddressed by clinicians, is the strong bidirectional relationship between sleep disorders and serious medical problems in older adults. Hypertension, depression, cardiovascular disease, and cerebrovascular disease are examples of diseases that are more likely to develop in individuals with sleep disorders. Conversely, individuals with any of these diseases are at a higher risk of developing sleep disorders. The goals of this article are to help guide clinicians in their general understanding of sleep problems in older persons, examine specific sleep disorders that occur in older persons, and suggest evidence- and expert-based recommendations for the assessment and treatment of sleep disorders in older persons. No such recommendations are available to help clinicians in their daily patient care practices. The four sections in the beginning of the article are titled, Background and Significance, General Review of Sleep, Recommendations Development, and General Approach to Detecting Sleep Disorders in an Ambulatory Setting. These are followed by overviews of specific sleep disorders: Insomnia, Sleep Apnea, Restless Legs Syndrome, Circadian Rhythm Sleep Disorders, Parasomnias, Hypersomnias, and Sleep Disorders in Long-Term Care Settings. Evidence- and expert- based recommendations, developed by a group of sleep and clinical experts, are presented after each sleep disorder.

Diagnosis and management of geriatric insomnia: a guide for nurse practitioners

PURPOSE

To discuss the assessment, diagnosis, and management of geriatric insomnia, a challenging clinical condition of older adults frequently seen by primary care providers.

DATA SOURCES

Extensive literature review of the published research articles and textbooks.

CONCLUSIONS

Complaints of insomnia among older adults are frequently ignored, considered a part of the normal aging process or viewed as a difficult to treat condition. Geriatric insomnia remains a challenge for primary care providers because of the lack of evidence-based clinical guidelines and limited treatment options available. Effective management of this condition is necessary for improved quality of life, which is a primary issue for the elderly and their families. Therefore, geriatric insomnia warrants thorough attention from the nurse practitioners (NPs) who provide care for older adults.

IMPLICATIONS FOR PRACTICE

Undiagnosed or under treated insomnia can cause increased risk for falls, motor vehicle accidents, depression, and shorter survival. Insomniacs double their risk for cardiovascular disease, stroke, cancer, and suicide compared to their counterparts. Insomnia is also associated with increased healthcare utilization and institutionalization. NPs could play a central role in reducing the negative consequences of insomnia through a systematic approach for diagnosis, evaluation, and management.

Nonmotor manifestations of Parkinson's disease

Parkinson's disease (PD) is the second most common neurodegenerative disease after Alzheimer's disease. Traditionally, attention has focused on the motor symptomatology of PD, but it is now appreciated that the nonmotor symptoms affecting neuropsychiatric, sleep, autonomic, and sensory domains occur in up to 88% of PD patients and can be an important source of disability. Nonmotor manifestations of PD play a significant role in the impairment of disease-related quality of life. The cause of nonmotor manifestations of PD is multifactorial, but to a large extent, these manifestations are related to the nature of the neurodegenerative process and the widespread nondopaminergic neuropathological changes associated with the disease. Recognition of nonmotor disability is essential not only for ascertaining the functional status of patients but also for better appreciating the nature of the neurodegenerative process in PD. In addition, a number of nonmotor manifestations can precede the onset of motor symptoms in PD and can be used as screening tools allowing for early disease identification and for trials of possible disease-modifying interventions. This article reviews depression, sleep, and autonomic dysfunction in PD.

Decreased MT1 and MT2 melatonin receptor expression in extrapineal tissues of the rat during physiological aging

Aging is a complex process associated with a diminished ability to respond to stress, a progressive increase in free radical generation and a decline in immune function. Melatonin, a molecule with a great functional versatility exerts anti-oxidant, oncostatic, immunomodulatory, and anti-aging properties. Melatonin levels drop during aging and it has been speculated that the loss of melatonin may accelerate aging. This study was designed to elucidate whether aging involves responsiveness to reduced melatonin. Melatonin membrane receptor (MT1 and MT2) expression and MT1 protein expression were analyzed in extrapineal tissues (thymus, spleen, liver, kidney, and heart) of 3- and 12-month-old rats using real time polymerase chain reaction and western blotting analysis. Moreover, melatonin in tissues was measured by high performance liquid chromatography. We report for the first time, an age-related reduction in mRNA MT1 and MT2 expression levels as well as MT1 protein expression in all tissues tested except the thymus, where surprisingly, both melatonin receptor levels were significantly higher in 12-month-old rats and MT1 protein expression maintained unchanged with age. Diminished melatonin concentrations were measured in spleen, liver, and heart during aging. As a conclusion, physiological aging seems to exert responsiveness to melatonin and consequently, the loss of this potent anti-oxidant may contribute to onset of aging.

Sleep in hospitalized medical patients, part 1: factors affecting sleep

BACKGROUND

Multiple factors lead to sleep disturbances in hospitalized medical patients. Inadequate sleep can lead to both psychological and physiological consequences.

METHODS

A PubMed search was conducted using the terms: ("sleep deprivation," "sleep," or "insomnia") and ("hospitalized," "inpatient," "critical illness," or "acute illness") to review the published data on the topic of sleep in hospitalized medical patients. The search was limited to English-language articles published between 1997 and 2008. Subsequent PubMed searches were performed to clarify the data described in the initial search, including the terms "hospital noise," "hospital environment," "obstructive sleep apnea," and "heart failure."

RESULTS

Few articles specifically addressed the topic of sleep in hospitalized medical patients. Data were limited to observational studies that included outcomes such as sleep complaints and staff logs of wakefulness and sleep. In Part 1, we review normal sleep architecture, and discuss how major medical disorders, the hospital environment, and medications can disrupt sleep during hospitalization. In Part 2, we will propose an evaluation and treatment algorithm to optimize sleep in hospitalized medical patients.

CONCLUSIONS

Hospitalization may severely disrupt sleep, which can worsen pain, cardiorespiratory status, and the psychiatric health of acutely ill patients. Like vital signs, the patient sleep quality reveals much about patients' overall well-being, and should be a routine part of medical evaluation.

Cervical column morphology in adult patients with obstructive sleep apnoea

Cervical column morphology was examined in adult patients with obstructive sleep apnoea (OSA) and compared with the cervical morphology of an adult control group with neutral occlusion, normal craniofacial morphology, and no history of sleep apnoea. The sleep apnoea group consisted of 91 patients, 16 females aged 29-59 years (mean 49.4 years) and 75 males aged 27-65 years (mean 49.0 years). All patients were diagnosed with OSA by overnight polysomnography. The control group consisted of 21 subjects, 15 females aged 23-40 years (mean 29.2 years) and 6 males aged 25-44 years (mean 32.8 years). From each individual, a visual assessment of the cervical column was performed on the radiograph. Differences in the cervical column morphology, between the genders and the groups were assessed by Fisher's exact test and the effect of age by logistic regression analysis. In the OSA group, 46.2 per cent had fusion anomalies of the cervical column and 5.5 per cent a posterior arch deficiency. Fusion anomalies occurred in 26.4 per cent as fusions between two cervical vertebrae. Block fusions occurred in 12.1 per cent and occipitalization in 14.3 per cent. A posterior arch deficiency occurred in 2.2 per cent as a partial cleft of C1 and in 3.3 per cent as dehiscence of C3 and C4. No statistical gender differences were found in the occurrence of morphological characteristics of the cervical column. The fusion anomalies of the cervical column occurred significantly more often in the OSA group. The results indicate that the morphological deviations of the upper cervical vertebrae play a role in the phenotypical subdivision and diagnosis of OSA.

The effect of chronic disorders on sleep in the elderly

Sleep disorders are increasingly common as people age. Along with the numerous physiologic changes that occur with aging, sleep patterns are also altered. Inability to get to sleep, shorter sleep times, and changes in the normal circadian patterns can have an impact on an individual's overall well being. In addition, many common chronic conditions, such as chronic obstructive pulmonary disease, diabetes, dementia, chronic pain, and cancer, that are more common in the elderly, can also have significant effects on sleep and increase the prevalence of insomnia as compared with the general population. This is a result not only of the chronic medical illnesses themselves, but of the psychologic and social factors associated with the disease processes.

Are children just small adults? The differences between paediatric and adult sleep medicine

Several important physiological and maturational changes occur in sleep development during the paediatric age range, particularly during infancy and in early childhood. As the pathology of sleep apnoea is superimposed onto a developing and often plastic physiological system, children often show a different pathophysiology to their adult counterparts. These factors need to be incorporated into the evaluation of a child's sleep problems. Particular attention should be paid to the developmental stage of the child. Investigation, interpretation and subsequent management provide further unique challenges and during successive reviews predicted normal changes must also be taken into account. This review article discusses the important physiological and maturational changes that occur in sleep during childhood, some common paediatric sleep conditions and their presentation and the appropriate evaluation and management of these conditions. In the course of the discussion, we have stressed important differences between paediatric and adult sleep medicine.

Sleep and aging: 2. Management of sleep disorders in older people

The treatment of sleep-related illness in older patients must be undertaken with an appreciation of the physiologic changes associated with aging. Insomnia is common among older people. When it occurs secondary to another medical condition, treatment of the underlying disorder is imperative. Benzodiazepines, although potentially effective, must be used with care and in conservative doses. Daytime sedation, a common side effect, may limit use of benzodiazepines. Newer non-benzodiazepine drugs appear to be promising. Rapid eye movement (REM) sleep behaviour disorder can be treated with clonazepam, levodopa-carbidopa or newer dopaminergic agents such as pramipexole. Sleep hygiene is important to patients with narcolepsy. Excessive daytime sleepiness can be treated with central stimulants; cataplexy may be improved with an antidepressant. Restless legs syndrome and periodic leg-movement disorder are treated with benzodiazepines or dopaminergic agents such as levodopa-carbidopa and, more recently, newer dopamine agonists. Treatment of obstructive sleep apnea includes weight reduction and proper sleep positioning (on one's side), but may frequently necessitate the use of a continuous positive air-pressure (CPAP) device. When used regularly, CPAP machines are very effective in reducing daytime fatigue and the sequelae of untreated obstructive sleep apnea.