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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/ -119-

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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, 120

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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/ 121

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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 -122-

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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/ -123-

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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 -124-

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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. -125-

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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. -126-

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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 -127-

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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. 128

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REFERENCES 1 2 3 4 5 6 8 9 10 Hobson, W. and Pemberton, J., The Health of the Elderly at Home (London: Butterworth), 1955. McGhie, A. and Russel, S.M., Subjective assessment of normal sleep patterns. Journal Mental Science 108:642-654, 1962. . . . Karacan, I., Williams, R.L., Littell, R.L., et.al., Insomnia: unpre- dictable and idosyncratic sleepers. In Sleep: Physiology, Biochemistry, Psychology, Pharmacology' Clinical Implications, Ede by WePe Koella and P. Levin, (Baser, Switzerland: Se Karger), 1973. Kales, A., Kales, JeDe' and Bixler, E.O., Insomnia. An approach to management and treatment. Psychiatric Annals 4 (7~: 28-44, 1974. Ballinger, C.B., Subjective sleep disturbance at the menopause. Journal of Psychosomatic Research 20~5) 509-513, 1976. Williams, R.L., Karacan, I., Thornby, J.I. and Salis, J., The electroencephalogram sleep patterns of middle-aged males. Journal of Nervous and Mental Disorders 154(1): 22-30, 1972. Tune, G.S., Sleep and wakefulness in normal human adults. British Medical Journal 2:269-271, 1968. Tune, G.S., Sleep and wakefulness in 509 normal adults. British Journal of Medical Psychology 42:75-80, 1969. Tiller, P., Bed, rest, sleep and symptoms: A study of older persons. Annals of Internal Medicine 61: 98-105, 1964. . Agnew, H.W.,Jr., Webb, W.B. and Williams, R.L., Sleep patterns in late middle aged males; An BEG study. Electroencephalography and Clinical Neurophysiology 23:168-171, 1967. -129-

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11 12 13 14 15 16 17 18 19 20 Brezinova, V., The number and duration of the episodes of the various EEG stages of sleep in young and older people. Electroen- cephalography and Clinical Neurophysiology. 39~3~:3273-278, 1975. Feinberg, I., Changes in sleep cycle patterns with age. Journal of Psychiatric Research. 10:283-305, 1974. Feinberg, I. and Carlson, V.R., Sleep patterns as a function of normal and pathological aging in man. Archives of General Psychiatry 18:239-250, 1968. Feinberg, I., Koreska, R.L., and Heller, M., EEG sleep patterns as a function of normal and pathological aging in man. Journal of Psychiatric Research 5: 107-144, 1967. Hursch, CeJe ~ Karacan, I., and Williams, R.L.' Stage 1-REM from infancy to old age. Sleep Research 1:87, 1972. Kahn, E. and Fisher, C. The sleep characteristics of the normal aged male. Journal of Nervous and Mental Disorders 148:474-494, 1969. - Kahn E, Fisher, C. and Lieberman, L. Sleep characteristics of the human aged female. Comprehensive Psychiatry 11:274-278, 1970. Kales A., Wilson T., Kales J.D., Jacobson, A., Paulson, M.J., Kollar, E., and Walter, R.D., Measurements of all-night sleep in normal elderly persons: effects of aging. Journal of the American Geriatric Society 15:405-414. Keane, B., Smith, J., and Webb, W. Temporal distribution and ontogenetic development of EEG activity during sleep. Psycho- physiology 14~3~:315-321, 1977. Lairy, B.F., Cor-mordret, M., Faure P., and Ridjanovic, S., Electro- encephalographic study of sleep in the aged, normal and pathologic. Rev Neural (Paris) 107:202, 1962 -130-

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21 22 23 24 25 26 27 28 29 30 Passouant, P., Bertrand, L., Delange, M., Baldy-Moulimier, M., Cabanae, P., and Descomps, B., Arteriosclerosis and sleep. Study of night sleep in the aged over 80 years old. Rev Oto-Neuro-Ophalmol (Paris), 35:1, 1963. Prinz, P.N., Sleep patterns in the healthy aged: relationship with intellectual function. Journal of Gerontology 32~2~: 179-186, 1977. Roffwarg, H.P., Dement, W., and Fisher C., Preliminary observations of the sleep-dream pattern in neonates, infants, children, and adults In Monographs on Child Psych, ed. by Maarms, E. (New York: Pergamon Press), 1964. Saradzhishvil, P.M., Geladze, T. Sh., Ribileishvili, Sh. I, Shubladze, G. and Toidze, O., Sh., (Clinical sleep patterns of long living males.) Soobshenheniya Akademii Nauk Cruzinskoy SSR (Tbilisi) 75~3~:693-695, 1974. (Russ.) Webb, W.R. and Swinburne, H., An observational study of sleep in the aged. Perceptual & Motor Skills 32~3~: 895-898, 1971. Williams, R.L., Karacan, I., Hursch, C.J., Electroencephalograph of Human Sleep: Clinical Applications. (New York: (John Wiley), 1970. Kales, A., Personality patterns in insomnia, Theoretical Implications. Archives of General Psychiatry 33~9~:1128-1134, 1976. Guttman, D., A survey of drug-taking behavior of the elderly. National Institute on Drug Abuse; Services Research Report, 1977. Basen, M.M., The elderly and drugs -- problems, overview, and program strategy. Public Health Reports 92~1~:38-43, 1977. Task Force on Prescription Drugs, Fina1 Report. U.S. Dept. HEW, Washington, DC, p. 2, 1969. -131-

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31 32 33 34 35 36 37 38 39 40 41 Hoddinott, B.C., Gowdey, C.W., Coulter, W.K., and Parker, J.M., Drug reactions and errors in administration on a medical ward. Canadian Medical Association Journal 97:1001-1006, 1967. Fracchia, Jo ~ Sheppard, Ce ~ Canale, D., Ruest, E., Cambria, E.' and Merlis, Se ~ Combination drug therapy for the psychogeriatric patient: Comparison of dosage levels of the same psychotropic drugs, used singly and in combination. Journal of the American Geriatric Society XXIII(11):508-511, 1975. Hollister, L.E., Prescribing drugs for the elderly. Geriatrics 32: 71-73, 1977. Learoyd, B.M., Psychotropic drugs and elderly patients. Medical Journal of Australia. 1:1131-1133, 1972. Food and Drug Administration: Task Force on Prescription Drugs. U.S. Government Printing Office, Washington, DC, 1968. Subcommittee on Long Term Care of the Special Committee on Aging, United States Senate. Nursing Home Care in the United States: Failure in Public Policy. Introductory Report, November 1974. Miles, L.E. and Dement, W., Sleep and Aging. Paper prepared for the National Institute on Aging Conference on Sleep and Aging, June, 1978. U.S. Public Health Service. Phsyician's Drug Prescribing Patterns in Skilled Nursing Facilities. U.S. DREW. June 1976. Mulligan, A.F., O' Grady, C.P., Reducing night sedation in psycho- geriatric wards. Nursing Times. 67~35~:1089-1091, 1971. Henning, J., Drug interactions: two are not always better than one. Modern Health Care. pp. 38-42, 1975 Schwartz, D., Wang, M., Zeitz, L., Goss, M., Medication errors made by elderly, chronically ill patients. American Journal of Public Health 52~12~:2018-2029, 1962. -132-

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