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Chapter 5
SLEEP DISTURBANCE IN THE ELDERLY
The complaint of insomnia in the elderly is perceived as one of
their more common problems. But because of its subjective definition,
insomnia in the elderly is one of the disorders that medical practi-
tioners understand least. A review of the literature reveals many
changes in the sleep/wake cycles occuring with age. The relevance of
these changes in terms of age-associated disease or deterioration,
normal evaluation, or artifact, is usually no less confusing than the
etiology of aging or the reason for sleep itself.
The main emphasis of this chapter is the 95 percent of the elderly
who are ambulatory and largely self-sufficient, but whose age-related
physical problems cause them to consume much more drugs than younger
segments of the population. Of particular concern is the regular
and prolonged use by this group of sleep-inducing medications that are
of dubious value, and that add new hazards to their already complicated
drug intake regimens.
A. Prevalence of Sleep Disturbance in the Elderly
There is some uncertainty about the incidence of sleep complaints
in the general population, but it is widely conceded that elderly
people have a greater incidence of sleep complaints than the young or
middle aged. Relevant data on sleep habits of the elderly, however,
usually have been accumulated as part of studies of several age groups.
An early study of sleep in the aged in Great Britain, indicated
that sleep complaints were quite frequent in the elderly, with 35
percent of those over 60 years of age claiming to awaken several times
per night. 1/ A questionnaire study of more than 2,400 subjects in
Scotland found high correlations between advancing age and decreased
sleep. 2/ Another study of 1,645 adults showed sleep disturbance to
increase with age and to be higher among females than males. 3/ The
Los Angeles Metropolitan Survey found that the respondents in the young-
est age group (18-29) complained less frequently of insomnia than
respondents over 60 years of age. In both age groups, females had more
complaints. 4/
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In a 1976 survey, difficulties with sleep onset and "waking after
sleep onset" (but not early morning awakening) were more frequent in
women following onset of the menopause. Hormonal changes at the time
of menopause are often cited as a temporary and presumably benign cause
of sleep disturbances. 5/ Menopause and middle age have been suggested
as a transitional phase in the development of sleep patterns in the
life cycle. 6/
Advancing age has been found to be associated with earlier sleep
onset, increased number and duration of wakings after sleep onset,
and increased number and duration of daytime naps. 7/ A study of
healthy office patients 6() years of age or over, found complaints of
insomnia were slightly higher ~ 21 percent) than the 15 percent generally
given for the population at large. 8/
Sal zman and Shader included decreased abil ity to sleep among the
signs and symptoms of depression in the elderly. They warn, on the
other hand, that "Lassitude, sleepiness, or apathy, which may be part
of retarded depressions in younger adults, are more likely to be signs
of physical disease, abnormal physical function, or drug toxicity in
the elderly." These symptoms of sleep and energy disturbance often
mask or mimic depression with the consequence of potential misdiagnosis
and inappropriate treatment of the elderly person. 9/
Surveys have found an increased incidence of subj ective sleep
complaints among the elders y. Whether these changes are a sign of
"maturation" or "deterioration" is unclear. Many nonspecific com-
plaints of sleep disturbance, awakenings during the night, and the
use of hypnotics all increase with age. TIomen appear to have a higher
incidence of complaints in all categories, as revealed in numerous
surveys .
Obj ective sleep measurements also show changes in apparently
"normal" aged men and women. Polygraph studies of sleep are, with few
exceptions, consistent with the subj ective survey data. 10/-26/ Stage
4 ("deep") of MREM sleep declines markedly with age, especially among
males. All studies show an increase in the number and duration of
awakenings during the night and an increase in Stage 1 ("light" ~ UREA
sleep. Surprisingly, the time it takes to fall asleep does not change
significantly with age, and the total sleep time shows either no change
or a small decrease. Although aged women have a greater incidence of
subj ective sleep complaints, men show a greater change in obj ective
sleep parameters with advancing age.
Much less information exists concerning the nature and incidence
of significant sleep pathology in the elderly. Art unpublished 1~78
study at the Stanford Sleep Disorders Clinic of six apparently normal,
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aged sub j ects found that two had sleep respiratory patterns typical
of sleep apnea. Of patients over 65 referred to the Stanford group
with insomnia, 18.6 percent ( 11 patients) were found to have central
sleep apnea.
Factors other than overt sleep pathology can g ive rise to a com-
plaint of insomnia. Patients may be complaining of the ''normal changes"
in sleep patterns, or the complaints may reflect general dysphoria,
anxiety, and depression without a clear-cut sleep disturbance. Strong
arguments have been made for a psycholog ical process underlying the
complaint of insomnia. 27/ Little or no study has been made of many
other factors: daytime sedation with major and minor tranquilizers,
chronic bedrest, organic brain disease, changes in circadian rhythms.
The etiology of sleep problems in the aged is usually viewed as a
mixture of medical, psychological, social, and developmental factors:
medical disorders, pain, depression, loneliness, absence of regular
activities and interests, the imposition of living alone or in a
nursing home environment, long daytime naps, worry about financial
problems or health, loss of self-esteem and social rewards associated
with work, and the normal ag ing process .
All of these factors must be considered in arriving at a diagnosis
and - prescribing a pharmacolog ic or nonpharmacolog ic approach to the
remediation of the symptom.* If a pharmacologic regimen is to be insti-
tuted, the diagnosis of depression would probably overrule the prescrip-
tion of hypnotics in favor of antidepressants or other measures. Rever-
sible or chronic brain syndromes must be ruled out as well. Prescription
of hypnotics can exacerbate rather than alleviate symptoms in these
patients .
B. Hypnotic Drug IJse by the Elderly
The elderly consume a disproportionately large amount of hypnotic
agents. In 1974, for instance, persons over 60 made up only 15 percent
of the population but received approximately one-third of secobarbital
and diazepam prescriptions. 29/ Part of the explanation is that older
* ~ ~ . Guttman, ''Many elderly people must deal with feel ing s
of loneliness, boredom, frustration and rolelessness, which often lead
to depression. Frequently, the response of doctors to these emotional
problems is to prescribe more drugs. Because of the realistic close-
ness to death, some doctors may rej ect psychotherapy in treatment
arm opt instead for the more expedient psychopharmaceuticals." 28/
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persons use more of all kinds of drugs: 11.4 prescriptions annually for
each person over 65, in contrast to 4.0 for younger adults. 30/ The
number of toxic interactions of drugs predictably increases with the
number of drugs consumed. 31/ One problem is that physicians do not
always decrease dosage when prescribing additional medications for
patients already receiving one psychoactive drug. In a study of
geriatric psychiatry patients in the VA system, physicians continued
the same dosage (and often increased it) when giving patients addi-
tional psychoactive medication. 32/ A second cause for the increased
incidence of toxic reactions in older patients- is the decreased ability
to metabolize and excrete drugs in old age. 33/ The medical problems
resulting from these factors is illustrated by the report of an
Australian geriatric psychiatry unit, which found that one out of
five admissions was due to toxic drug reactions. 34/ About half
of these related to hypnotic or tranquilizer use, and the majority
of all toxic states cleared when medications were discontinued.
The pattern of prescription drug use by the elderly is emphasized
by statistics from the Food and Drug Administration, 35/ the Subcom-
mittee on Aging, and Subcommittee on Long-Term Care of the U.S. Senate
Special Committee on Aging. 36/ Twenty-five percent of the nation's
prescription drugs are used by those over 65 although they make up only
10 percent of the present U.S. population. Drug misuse is a negative
health behavior that exists among adults of all ages; however, the
older person is more likely to experience problems resulting from
inappropriate drug use. The aging process seems to correlate highly
with chronic conditions and diseases that require chemotherapy.
In a telephone survey of the insomnia problems of 549 non-
institutionalized individuals in the San Francisco Bay area, 48
percent of those over 65 reported use of sleep medication "every
night" or "frequently," which was the highest percentage for any
age group. _ / The pattern of sedative-tranquilizer use in the
elderly is also indicated by a study of 447 noninstitutionalized
elderly subjects in the Washington, D.C. area. Sixty-two percent
of respondents took prescription drugs daily; of these 13.6 percent
were receiving prescription sedative-tranquilizers daily. Of those
receiving sedative-tranquilizers on any dosage schedule, 40 percent
took them daily, 40 percent only when needed, and 20 percent one
or more times a week. 28/
The use of hypnotics in geriatric institutions has been the
subject of much criticism. A U.S. Public Health Service survey of
physicians' prescribing patterns in skilled nursing facilities
showed that prescriptions for sedative-hypnotics were written for
94.2 percent of the 98,505 patients studied. 38/ More than half of
189 patients in another institutional setting were found to be
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receiving some hypnotic medication nightly. 39/ Probably much of the
tendency for routine or prophylactic use goes back to the time-honored
practice of prescribing bedtime sedation routinely in general hospitals.
Although the medical profession is often blamed for "pushing
pills," the elderly often seek and prefer chemical solutions to their
ills and will medicate themselves. When the promised result is not
achieved, the tendency is to use more drugs. 40/ Socioeconomic factors
also play an important role in drug-taking behavior of the elderly.
Difficulty in living on fixed incomes motivates them to turn to over-
the-counter preparations and home remedies to avoid the cost of a
doctor's visit. Fear, ignorance, or lack of transportation often
contribute to potential overuse or misuse of drugs by the elderly. 41/
Several common and potentially dangerous self-medication behaviors
have been identified as examples of drug misuse: 41/-43/ lack of
knowledge of what constitutes a side effect; taking medicines
irregularly because of lack of motivation; forgetfulness, expense, or
self-determination of need; borrowing and lending medicines; saving
old medications and using them to self-treat problems; mixing different
drugs in one container; and overdosage by the ingestion of duplicate
medications prescribed by different physicians. Complicating the
problem is a lack of specified geriatric drug doses. Existing experi-
mental data on drug metabolism are usually obtained from adults in
their mid-twenties. _ /
C. Pharmacologic Treatment of Insomnia in Elderly Patients
Efficacy and Safety of Hypnotics
Pharmacologic problems of aging result from changes in body
composition, such as decreased percentage of fatty tissue to absorb
lipid-soluble drugs, decreased plasma albumin (a major source of
drug binding), decreased number of intestinal absorbing cells, and
decreased intestinal blood flow, which may limit drug absorp-
tion. _/,45/ The ability of the liver to metabolize drugs is
decreased. Large decreases in renal blood flow lead to impaired
ability to excrete drugs. 45/ The combined result of these changes
is that many drugs tend to remain in the body longer, which suggests
that drugs with inactive metabolites or with relatively short half-
lives would be more suitable for elderly patients. The commonly
prescribed benzodiazepines have active metabolites with long half-
lives, properties that have led to the recommendation that they be
used at one-half the usual adult dosage when prescribed for patients
over 70. 46/
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A review of studies of efficacy of hypnotics reveals that very few
are specifically tested in the elderly, and many of these are on a
special population -- nursing home or chronic care patients. Patients
and nurses reported about equal effectiveness in six studies comparing
hypnotic barbiturates with benzodiazepine hypnotics and nonbenzodiaze-
pine, nonbarbiturate hypnotics. 47/-52/
Clinical (subjective) studies of hypnotics in geriatric populations
have yielded results that appear to be more favorable than those generally
obtained in sleep laboratory studies of younger adults. Every hypnotic
evaluated in these clinical studies is effective by one or more criteria.
These conclusions are weakened by the apparent effectiveness of placebo
in some cases, and by the lack of certainty that any of the patients
studied needed hypnotics or had a true sleep disturbance.
Conclusions that seem to be valid from these studies are that
little data at all, and virtually no EEG data, exist on efficacy of
hypnotics in the elderly, and that no single agent is clearly more
efficacious than others.
Adverse reactions in the elderly to psychoactive drugs include
intoxication, secondary complications, such as drug-induced hypo-
tension, and disinhibition reactions such as restlessness and
aggression. The latter, which are particularly troublesome, have
often been associated with barbiturates, but do occur with all classes
of hypnotics. 34/ The literature suggests that the toxicity profile
of a given hypnotic may be very different in young adults compared
to the elderly. Thus chloral hydrate, which enjoys a reputation of
minimal side effects, has been known to produce confusion and hallu-
cinations in a substantial number of nursing home patients. 51/
Flurazepam has an increasing incidence of toxic side effects with
progressive age. Reports about this drug have ranged from
generally mild side effects in 7.1 percent of patients over 80 53/
to a spectrum of generally more severe problems such as ataxia,
confusion, and hallucinations in 26 percent of nursing home patients
over 60 years old. 54/ When clinically significant drowsiness is
considered, phenobarbital (in contrast to the benzodiazepines) does
not show an age-related increase in difficulties. 55/ The net result
is that in patients over 60, the incidence of undesirable daytime
drowsiness may be about the same (11 to 12 percent) with pheno-
barbital, diazepam, and chlordiazepoxide. 55/ Nitrazepam 10 ma, when
given for 14 days to geriatric psychiatry patients, significantly
impaired memory, coordination and, ability to conduct life events
compared with placebo in approximately half of the patients. 56/
As noted above, those few studies that are performed on the
elderly typically examine a special population -- nursing home or
chronic care patients. Thus the possibility of sampling error when
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generalizing to elderly patients as a whole remains high since ninety-
five percent of the elderly are ambulatory and living in the community.
Some Clinical Issues
A thorough evaluation of the medical, neuropsychiatric, and
psychosocial status of the elderly patient is essential before con-
sidering approaches to relieve insomnia.
(a) If a patient is suffering from a depressive syndrome,
pharmacotherapy and other measures should be directed to treating
the depression. Antidepressant drugs that are least anticholinergic
should be selected (e.g., desipramine) so as to minimize side effects
of urinary retention, exacerbation of glaucoma, and mental confusion.
Unfortunately, those antidepressant drugs thought to be the most
"sedating" and most likely to promptly be helpful with sleep distur-
bance in depression (e.g., amitriptyline and doxepin) are also the
most powerfully anticholinergic and thus should be avoided for most
elderly patients.
(b) If the insomniac patient is confirmed as suffering from
senile brain disease or some other organic brain syndrome, then the
sleep disturbance probably will not respond to hypnotic medication.
Hypnotics and daytime sedatives or "minor tranquilizers" often tend
to worsen such patients' agitation. Some patients can be successfully
sedated at night by neuroleptics (antipsychotic drugs or "major
tranquilizers") but with a substantial risk of anticholinergic side
effects. Episodes of postural hypotension can lead to falls and
fractures. A serious potential problem is the induction of irrever-
sible tardive dyskinesia -- a disorder of involuntary facial and bodily
movements -- in patients treated with neuroleptics. The benefit/risk
determination in these situations is often a difficult one to make.
(c) Other elderly insomniac patients may or may not benefit from
hypnotic drugs. Their sleep disturbance is often baffling and
apparently intractable. A great many develop nightly dependence on
hypnotics. The hazard of prescribing any drug that depresses
respiratory responses during sleep is a major consideration with this
age group (see Chapter 4~. Middle-of-the-night disorientation may
be worsened by hypnotics, and this may be associated with falls and
hip fractures. 57/
(d) For many patients, including those for whom pharmacotherapy
is employed, psychosocial interventions will be appropriate and
necessary.
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Factors in the Choice of hypnotics
The data that are necessary to determine which agents are most
effective and-least toxic in the elderly are not available at this time.
It would seem reasonable that drugs that are converted to inactive
metabolites ate have relatively short half-lives generally would be most
desirable. Such drugs include barbiturate hypnotics, chloral hydrate,
methyprylon (Noludar(R)), and diphenhydramine (Benadryl(R)~. These older
drugs have drawbacks, but they do not ordinarily accumulate in the
body with repeated use, as do the commonly prescribed benzodiazepines
(flurazepam and diazepam). The disadvantages of the barbiturates and
chloral hydrate lie in their toxicity when taken in suicide attempts
and their interference with the metabolism of certain other medically
needed drugs, such as, anticoagulants. The disadvantage of diphen-
hydramine is that it is somewhat anticholinergic and could cause
unwelcome side effects. Apparently, methyprylon has not been evaluated
for use in a geriatric population.
The accumulating benzodiazepines (e.g., diazepam, flurazepam,
nitrazepam) have been linked to increased rates of adverse reactions
in elderly patients on frequent or prolonged medication.* 53/-55/
Many of these reactions are not adequately diagnosed. 55/ A confused
mental state that arises after a month or two of nightly (or three
times weekly) hypnotic drug use is often mistakenly diagnosed as
irreversible "dementia" or "senility" because physicians and nurses
do not attribute the symptoms to the drug. (A patient is more
fortunate when adverse drug reactions develop promptly, because
family members and health care personnel naturally will be more
alert to the possible association with a newly started medication.)
Thus, if flurazepam is to be prescribed, consideration should be
given to forestalling accumulation of its metabolites by dosing
on a two times per week, or less, basis.
Studies of cognitive functioning, psychomotor performance, and
blood levels during chronic administration to the elderly are needed
before final judgments on the relative safety of these agents can be
made. In the meantime, the prudent dictum is that sedatives and
hypnotics should be prescribed conservatively and in low doses.
Because the elderly tend to have increased toxicity from pharmaco-
therapy in general, it is to be hoped that clinical investigators who
are developing nonpharmacologic treatments for insomnia will especially
emphasize applicability to older patients.
-
*Recent pharmacokinetic studies of the shorter-acting benzodiaze-
pine anxiolytics - oxazepam (Serax(R)) and lorazepam (Ativan (R)) --
indicate that there is no impairment of their disposition and elimina-
tion in aged subjects as compared to younger adults. 69/ Their
effectiveness as hypnotics has not been clinically assessed as yet.
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D. Non-pharmacological Treatment of Sleep Disturbance
Sleep disturbances represent a knotty problem for the elderly
person, for the family, for the physician, or for the hospital/nursing
home staff. Physicians prescribing sleeping pills to the elderly must
be clear in their own minds whether they are treating the patient,
or treating his family or the hospital/nursing home staff who are
disturbed by the patient's awakening during the night. The physician,
even when recognizing that normal sleep is a problem for the elderly,
that hypnotics cease to be an effective solution to the problem, and
that the elderly are vulnerable to adverse drug reactions, often
may decide that prescription of sleeping medication is appropriate
because of lack of alternatives.
Nonpharmacological techniques of establishing a ritual for nocturnal
sleep appear to hold promise, but little has been done to document the
effectiveness of these therapeutic measures and thus encourage applica-
bility to the wider population with sleep difficulties. Butler and
Lewis suggest some nonpharmacologic methods for remediation of insomnia
in ambulatory patients
". . . Psychotherapy can help to understand
the individual's basis for insomnia. The
establishment of simple rituals is in order,
warm tubs, well made bed, bed boards for
support, back massage, wine, warm saki
(Japanese rice beer) are all simple measures
that should be tried before hypnotic drugs
are used. There should be no t standing
orders' on hypnotics. They should be
reevaluated routinely. Active, pleasurable
sexual activity, including masturbation,
can be excellent sleep inducers.t'58/
Insomnia is a particular problem for aged persons who go to bed
early and take catnaps during the daytime, -- sometimes a symptom
of impending day/night sleep reversal. These self-sufficient elderly,
who are no longer employed and who have failed to adjust or have not
yet begun to adjust to change in life role and other sequelae of retire-
ment, often find their daytime hours unusually conducive to sleep. It
is this pattern of daytime sleep that must be changed instead of
treating the night-time insomnia that results from it. It has been
suggested that setting up new schedules with set times for rising,
meals, exercise, etc. can be effective. This kind of prescription
requires the assistance of persons such as social workers, or visiting
nurses who are able to make home visits (sometimes unannounced) to
check on progress in establishing the new routine. Assistance in
the management of this situation can also often be found in the natural
associations that people have and depend on -- families, friends, and
neighborhood social networks. A study comparing users of psychotropic
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drugs with users of all types of prescription drugs predictably found
that persons describing their family relationships as satisfactory
took less sedatives, while those who described their family relation-
ships as unsatisfactory took more sedatives. 28/
The natural helping networks existing independently of professional
caregi~rers aTx1 formal caregiving institutions may be a key mechanism
for providing elderly persons with a sense of "belonging," to counteract
the sense of loss attending a change in life roles. The Report of
the Task Panel on Community Support Systems of the President' s Commission
on Mental Health ( 1978) details the value of these supportive networks
and the effectiveness of formal and informal support systems in enhancing
the lives of elderly persons. 59/
There is a body of research to suggest that social supports have
a direct effect on health by mediating the impact of stress and by
strengthening the individual' s coping efforts . 6()/-62/ The relationship
between social support, systems and utilization of health services,
however, is not simple. It has been shown that absence of an adequate
social support system can lead either to inability to use health
services or to an increased use of these services when the problem
is not disease, but the need for human support. The presence of social
support may lead to increased use or decreased use of health ser-
vices, 63 /-64/ d Depending on the content of the support given. When a re-
sponse is sought from the medical care system, rather than from the social
support system the risk of ineffective and costly treatment is high.
Additionally, the inappropriate utilization of medical technology also
has attendant risks of increasing the likelihood of iatrogenic illness.
The medical care system itself can be a social support system. In some
instances it is the only resource people have in times of stress.
Studies of the doctor-patient relationship have demonstrated that for
some problems the personal qualities of the health care provider and
the mode of interaction utilized have greater therapeutic value than
technolog ical interventions such as drugs . 65 /-66/
The milieu in senior citizen residences, extended care homes,
or similar group-living arrangements, often promotes behaviors such
as daytime naps, and an understimulated, sedentary life style; such
behavior impairs overall adj ustment and daytime functioning, and
contributes to the emergence of nocturnal sleep disturbance. In
our society the elderly do little physical work; yet some studies have
ind icated that physical exercise will reduce daytime sleepiness . 67 /-68 /
It might therefore be assumed that a substantial increase or reduction
in the amount of daytime physical work or recreation would modify
sleep and the symptoms of sleeplessness. In this instance programmatic
initiatives to provide activities for utilizing the energies of the
elderly in physical exercise programs and opportunities in group
meeting s to ventilate worries and disappointments, for example, could
furnish release for the physical tension and psycholog ical stress
that many elderly persons experience.
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Representative terms from entire chapter:
sleep patterns
