Growing Old Should Not Mean Sleeping Poorly: Recognizing and Properly Treating Sleep Disorders in Older Adults

Fragoso and Gill provide a masterly, comprehensive overview of the causes of sleep disorders in older adults, emphasizing the multifactorial origin of most sleep disturbances in this population, and provide a clinical application of these principles.

Abstract

The last decade has been an exciting period for sleep research and sleep medicine, especially in the area of geriatric health care. There have been significant and rapid advances in our ability to diagnose and treat, behaviorally and pharmacologically, sleep disorders generally and in older adults in particular. These important scientific and healthcare advances have been contemporaneous with other major movements in the sleep field, including the continued healthy growth of societies like the Sleep Research Society and the American Academy of Sleep Medicine, nonprofit foundations such as the National Sleep Foundation advocating the importance of sleep for health and safety, and the recent recognition of sleep medicine as a medical subspecialty. Within the context of burgeoning sleep research, medicine, and advocacy, the Institute of Medicine (IOM) of the National Academy of Sciences recently released a report entitled "Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem."1 This report recognizes that sleep disorders and sleep deprivation are significant public health problems that have a wide range of deleterious health and safety consequences. The IOM calls for increased awareness among healthcare professionals about the physiology of healthy sleep and sleep disorders across the lifespan and the development and implementation of programs to promote the early diagnosis and treatment of sleep disorders. Fragoso and Gill's review2 is a timely exercise of these recommendations in the context of geriatric healthcare practice. Fragoso and Gill provide a masterly, comprehensive overview of the causes of sleep disorders in older adults, emphasizing the multifactorial origin of most sleep disturbances in this population. They detail how age-related changes in homeostatic and circadian sleep regulatory mechanisms, changes in health and functional status, primary sleep disorders, and psychosocial influences can disturb sleep and how several of these factors are often simultaneously at play in an individual patient. They argue that, because of its multifactorial origins, sleep disruption can be conceptualized as a geriatric syndrome. They further incorporate these factors into the classic model of insomnia proposed by Spielman and colleagues,3 providing a useful heuristic for appreciating the intricacies of the interactions between the various causes of sleep disturbance and health. Finally, they provide a clinical application of these principles and close with the recognition that appropriate treatment of sleep complaints in older adults requires a comprehensive geriatric assessment, sensitivity to the multiple causes of sleep disturbance common to this population, and recognition that effective treatment needs to be comprehensive, iterative, and long term. Fragoso and Gill have gone a long way toward ensuring that older adults, with appropriate diagnosis and treatment of the underlying factors, can obtain the best sleep possible and are not consigned merely to getting the sleep they do, because they are simply "getting older." That epidemiological studies show that 50% of older adults complain of significant sleep disturbance is a cliché of the sleep and aging literature. The other 50% do not complain, suggesting that aging, per se, clearly does not result in more sleep complaints.4 The accepted wisdom has been that the age-related sleep changes begin to appear in early adulthood and progress steadily across the adult human lifespan, although a recent meta-analysis of studies by Ohayon et al. using objective sleep measures across the human lifespan5 demonstrated that, in healthy, carefully screened, non-complaining adults, the bulk of the changes seen in adult sleep patterns occur between early adulthood and age 60, declining only minimally from age 60 to age 102. This and other studies6,7 clearly indicate that aging in the later human life-span, per se, has a relatively small effect on sleep quality. Rather, as Fragoso and Gill point out, factors that form the fabric of usual, as opposed to healthy, aging such as "reduction in health status, loss of physical function, and primary sleep disorders … are capable of precipitating sleep complaints and adverse outcomes." That is, the factors that impair sleep in older adults are diagnosable and treatable.8 Much progress has been made in understanding sleep disturbances in older adults; advances include improvements in the behavioral and pharmacological management of insomnia and better recognition and treatment of sleep apnea and restless legs syndrome,8 but the journey is far from complete. Better, more-specific behavioral and pharmacological interventions need to be developed. More attention needs to be paid to the sleep of older adults with degenerative neurological disorders and their caregivers, whose sleep is often greatly compromised as well, more attention needs to be paid to improving the sleep of institutionalized older adults, and finally, primary care physicians need not only to take the sleep complaints of their older patients seriously, but also need to query their patients, regardless of age, about their sleep.9 In the spirit of ensuring that the sleep disturbances so common in older adults are appropriately recognized, diagnosed, and treated, another movement is particularly timely and in total harmony with the IOM Report and Fragoso and Gill's review. The International Longevity Center (ILC), long a forceful advocate for addressing population aging and longevity concerns worldwide, has recently organized the National Coalition for the Development of Clinical Practice Guidelines for Sleep Disorders in Older People, a rapidly expanding consortium that currently consists of 12 member organizations, including among them the American Geriatrics Society. As is apparent from the coalition's name, its goals are to raise awareness of the importance of appropriately treating sleep disturbance in older adults and, perhaps more importantly, to develop evidence-based practice guidelines for sleep disorders that will become a standard part of geriatric healthcare practice. This is an exciting time to be involved in geriatric sleep research and in sleep medicine as it relates to geriatrics. Although much remains to be done, evaluative documents like the IOM Report, development efforts like the ILC Coalition, and scholarly clinical reviews like that of Fragoso and Gill all help ensure that older adults need not sleep poorly simply because of their age. Conflict of Interest: Michael Vitiello received honoraria as part of the speaker's bureau of Takeda Pharmaceuticals. The editor in chief has determined that the author has no conflict of interest related to this manuscript. Author Contributions: Dr. Vitiello is the sole author responsible for all content. Sponsor's Role: None.