Sleep-related disorders are common in the general adult population, and as the population ages, the prevalence of these disorders increases. A common misconception among clinicians and the public is that this increased prevalence is a normal and expected phenomenon of aging. However, this higher prevalence of sleep disruption is often the result of the increased presence of medical, and psychosocial comorbidities in this population. The complicated multifactorial interactions that generate sleep disorders in older individuals pose important challenges to clinicians. Furthermore, many clinicians are unaware of the seriousness and potential morbidity associated with sleep problems in older people, distinct from the morbidity of concurrent disorders. As a result, these issues are often underinvestigated, or completely ignored.1
Because of the high prevalence, complexity, and health implications associated with sleep-related disorders in older individuals, increasing attention is now being focused on this topic. For example, a recent publication has recommended that sleep problems be approached as a “multifactorial geriatric syndrome.”2
Of major clinical concern is the strong bidirectional relationship between sleep disorders and serious medical problems in older persons. Individuals with sleep disorders are more likely to develop hypertension, depression, cardiovascular, and cerebrovascular disease. Conversely, individuals with any of these diseases are at higher than normal risk of developing sleep problems.3,4
Older individuals consider quality sleep to be an essential part of good health. A Gallup survey of over 1000 Americans age 50 and older (43% of whom were age 65 or older) found that 80% answered “a great deal” when asked whether sleep was important for healthy aging. In the same survey, and contrary to the myth that older adults need less sleep, 45% believed they required more sleep now than when they were younger and 25% believed they had a sleep “problem.”5
The goal of this paper is not to present an exhaustive and comprehensive review of sleep and sleep disorders in older persons. Rather, we present an overview of sleep disorders and suggest appropriate evidence-based recommendations for assessing and treating sleep disorders in the older adult population. These recommendations have been developed by professionals with expertise in sleep disorders and in the clinical care of older people.
As in many areas of clinical research, older persons are often poorly represented (or specifically excluded) in clinical sleep studies. Thus, there are less data available from randomized controlled trials for this population compared to the general adult population. Nevertheless, given the importance of the subject, and the opportunity for successful intervention, we believe it is prudent and timely to propose recommendations based upon expert consensus of current evidence. While there have been a number of publications aimed at clinicians concerning sleep and sleep disorders in the adult and older adult populations, there are currently no recommendations for systematically approaching the assessment, treatment and follow-up of sleep disorders in the older adult population. 2,6-11
In developing these recommendations we are cognizant of a number of important themes: 1) the tremendous heterogeneity of the older adult population, and thus the critical importance for individualization of assessment and therapy; 2) the limited amount of time clinicians have to spend with each patient, making lengthy assessments for sleep problems unrealistic; 3) the body of knowledge regarding the approach to assessment and treatment of sleep disorders that clinicians need to possess; 4) the role of sleep specialists in this process, and the importance of recognizing when and where to refer; and 5) the frequent presence of comorbidities and multiple medication usage in this population of patients, requiring a careful approach and meticulous follow-up.
Sleep-related problems in the acute care hospital setting will not be addressed in this paper. Such problems have received little attention in research studies compared to sleep problems in outpatients, and the state of knowledge concerning these conditions is inadequate to make recommendations with a reasonable level of confidence. In this paper, therefore, we focus on chronic problems with sleep in older persons in the outpatient and long term care setting.