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  1. Home
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  3. Principles and Practice of Geriatric Sleep Medicine
  • Cited by 3
Publisher:
Cambridge University Press
Online publication date:
August 2010
Print publication year:
2009
Online ISBN:
9780511770661
DOI:
https://doi.org/10.1017/CBO9780511770661
Subjects:
Geriatrics, Neurology and Clinical Neuroscience, Medicine
Information

Book description

Sleep disorders cause considerable morbidity and distress in the aging population. By highlighting the clinical diagnosis and management of sleep disorders, this volume provides a valuable resource for all those involved in health care of older individuals. The changes in sleep patterns that occur during normal aging are described, followed by authoritative chapters on the presentation of various age-related sleep disorders. The book deals with the range of therapeutic measures available for managing these disorders and gives insight to potential areas of research that have emerged in the last few years, such as the study of circadian rhythms in later life, sleep patterns associated with co-morbidities and the use of quality-of-life measurement tools to determine sleep quality as we age. This volume is relevant to sleep disorders specialists, psychiatrists, geriatricians and gerontologists, and any professionals and researchers working in the interdisciplinary areas of sleep and aging.

Reviews

'… an excellent, comprehensive text on an increasingly relevant subject.'

Source: Sleep Medicine

'Principles and Practice of Geriatric Sleep Medicine is a comprehensive, and much needed book for medical practitioners … It is edited by leaders in the field, and has contributions from most of the eminent researchers and international experts in the field of sleep medicine. … this book is well written and a pleasure to read. The chapters are well structured and succinct, and present a wealth of up-to-date research. … The content is diverse and is thus likely to appeal to many experienced clinicians. … I would highly recommend this book for any clinicians and researchers working in the ageing and/or sleep disciplines.'

Source: Acta Neuropsychiatrica

'Its 41 chapters bring together the expertise of researchers and clinicians representing the full range of specialities currently working at the interface of sleep disorders and aging. … the text can serve as a useful reference for those interested in exploring the field or who are looking to improve their ability to understand and treat sleep disorders in this population.'

Source: Neurology

'… a worthwhile contribution to the field of sleep medicine. … a comprehensive review of recent developments in the field.'

Source: Doody's

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Contents

Page 2 of 2

Contents
  • 17 - Effect of depression and anxiety on sleep in the elderly
    pp 183-194
  • View abstract

    Summary

    The chapter focuses on age-related changes in pathophysiological mechanisms in apneic and normal subjects, and on the potential relevance of the findings to obstructive sleep apnea (OSA). Aging has been reported to be a major factor affecting the risk of OSA. In the extremes of aging, some data suggest a survivor effect, such that apnea prevalence may decrease among elderly patients. The upper airway (UAW) requires stiffness of the soft tissue walls around it and activity of the dilator muscles to maintain patency. Any reduction in UAW cross-sectional area, change in its length, muscle activity, or a combination of these variables, may lead to vulnerability of the UAW to collapse. The term loop gain is used to refer to the intrinsic stability or instability in the ventilatory control system. Once the patient with apnea falls asleep and the cycle of repetitive airway obstruction begins, recurrent hypoxemia and hypercapnia develop.
  • 19 - Sleep and circadian rhythm disturbances in Alzheimer’s disease
    pp 214-226
  • View abstract

    Summary

    This chapter discusses the neuroendocrine function changes in the context of the hypothalamic-pituitary-adrenal (HPA) axis, the somatotropin axis, the hypothalamic-gonadal (HPG) axes, and the orexin-hypocretin system. It describes the thyroid axis as well as relationships with prolactin. The chapter links changes in sleep with aging with changes in neuroendocrine systems with aging. Some age-associated changes in HPA axis activity correlate with similarly associated changes in sleep. There is an age-related change in GH secretion. The inverse relationship between Growth hormone-releasing hormone (GHRH) and slow wave sleep (SWS) as well as between corticotropin-releasing hormone (CRH) and GHRH provide the basis for influences of GHRH on sleep in aging. Gonadotropin-releasing hormone (GnRH) is produced and released in the hypothalamus. The hypocretin-orexin system is important for influencing many aspects of sleep-related brainstem nuclei activity. Thyroid-stimulating hormone (TSH) is secreted in a circadian-dependent pattern with peak levels occurring during sleep.
  • 20 - Narcolepsy in the elderly
    pp 227-232
  • View abstract

    Summary

    Circulating melatonin is metabolized primarily in the liver, and secondarily in the kidney. Melatonin has been used successfully in the treatment of insomnia and circadian rhythm sleep disorders. Several studies show that melatonin levels are lower in Alzheimer's disease (AD) patients compared to age-matched control subjects. If the expectation of melatonin activity in AD is to be neuroprotective, the treatment must be initiated at the earliest possible stage of the disease. There is substantial evidence that fragmented sleep, advanced sleep phase syndrome, insomnia, and impaired daytime alertness seen in advanced age are the result of brain dysfunction that is closely linked to disruptions in the regulation of circadian rhythms. The aging process is multifactorial, and no single factor seems to be of basic importance. An example of the effect melatonin has on aging is that in AD and mild cognitive impairment (MCI) patients.
  • 21 - Movement disorders in the elderly
    pp 233-240
  • View abstract

    Summary

    This chapter examines the existing evidence relating reduced sleep duration and quality, as occurs in a majority of older adults, and the epidemic of diabesity. Blood levels of glucose are tightly regulated within a narrow range to avoid hypoglycemia and hyperglycemia as both conditions have serious adverse consequences. The release of growth hormone (GH) during early sleep contributes to prevent the decline of glucose levels. There is increasing evidence that age-related alterations in sleep quality may result in disturbances of endocrine function, raising the hypothesis that some of the hormonal and metabolic hallmarks of aging partly reflect the deterioration of sleep quality. Glucose regulation was assessed by intravenous glucose tolerance test (ivGTT) at the end of each of the two conditions, after two consecutive nights of undisturbed baseline sleep, and after three nights of suppression of slow wave sleep (SWS).
  • 23 - Sleep apnea in the elderly
    pp 248-259
  • View abstract

    Summary

    This chapter reviews the assessment and differential diagnosis of sleep disorders in the elderly. Cognitive deficits and sleep difficulties are normal age-related changes, may explain an elderly patient's complaints about sleep. There are also a variety of other diagnoses that must be considered, including the presence of specific sleep disorders, circadian rhythm disturbances, and medical and psychiatric co-morbidities. There are also several less common presentations of sleep disordered breathing (SDB) that can be found in the elderly, which include complaints of insomnia, nocturnal confusion, and daytime cognitive impairment such as short-term memory loss and poor concentration. As with younger patients, sleep complaints in older patients should be evaluated with a thorough sleep history and often an overnight sleep study. The appropriate diagnosis or identification of specific, often reversible or correctable factors contributing to an elderly patient's sleep complaint can result in significant improvements in quality of life and daytime functioning.
  • 24 - Sleep and cardiovascular diseases in the elderly
    pp 260-270
  • View abstract

    Summary

    Symptoms of abnormally early sleep are common in the elderly. Aging is associated with earlier habitual bedtimes and earlier morning wake-up times. Intrinsic disorders, are those in which the endogenous circadian regulation of sleep is itself abnormal. These intrinsic disorders include irregular sleep-wake rhythm, free-running disorder, and delayed sleep phase syndrome (DSPS), as well as advanced sleep phase syndrome (ASPS). Amplitudes of other circadian rhythms, including core body temperature, are also reduced with age, and post-mortem brain studies have revealed reductions in suprachiasmatic nucleus (SCN) volume, cell number, and neuropeptide rhythms, suggesting an age-related clock defect. Treatments recommended for ASPS include chronotherapy, timed melatonin administration, and timed light exposure. These treatments are all directed towards the primary goal in treating ASPS: to correct the abnormally early timing of sleep by delaying the circadian clock.
  • 25 - Insomnia in the elderly
    pp 271-279
  • View abstract

    Summary

    This chapter discusses whether shift work might be particularly harmful to men and women over 55 years of age. The essence of the problem for seniors who are shift workers therefore revolves around three interrelated concepts: age-related changes in the ability of the circadian system to phase adjust; age-related changes in the ability of the individual to stay awake and work in the late evening and overnight hours; and age-related changes in the ability of the individual to sleep at "unusual" times. Conventional wisdom asserts that seniors have flatter circadian rhythms, rendering the difference between day and night in their physiology less different for them than it is for younger adults. In addition to disorders of sleep and wakefulness, there appear to be both physical health and mental health consequences of shift work exposure. Social factors may also serve to render coping with shift work difficult.
  • 26 - Sleep in nursing home residents
    pp 280-288
  • View abstract

    Summary

    Nocturia has a detrimental influence on life expectancy, health, and overall quality of life. Its prevalence is fairly equal in men and women and shows an age-related increase in both sexes. There are numerous medical conditions that are associated with increased nocturnal voiding, such as cardiac diseases, diabetes, obesity, edemas of different origins, and sleep apnea. On the basis of analyses of information collected from frequency-volume charts, the pathophysiological conditions underlying nocturia can be categorized as: nocturnal polyuria, a low nocturnal bladder capacity, or a combination of the two. Clinical conditions should be treated as appropriately as possible before more specific treatment of nocturia is considered. Clinical trials have specifically addressed the use of medications for treating nocturia through improvement of bladder capacity. Estrogen treatment has been shown to have a favorable influence on urological symptoms in general, but studies indicating a specific effect on nocturia are lacking.
  • 27 - Fatigue and sleepiness in the elderly: risk factors and management strategies
    pp 289-298
  • View abstract

    Summary

    Fibromyalgia is a pain amplification syndrome produced by persistent afferent sensory stimulation and manifested as a central sensitization syndrome. Multiple studies including neuroimaging studies have consistently shown that fibromyalgia syndrome (FM) pain emanates from changes in the brain and spinal cord using the same mechanism that makes sunburnt skin sensitive to light touch. The role of sleep in the etiopathogenesis of fibromyalgia is underscored by the fact that up to 90% of FM patients have non-restorative sleep. The sleep disturbance should be investigated to ascertain whether periodic limb movement syndrome, sleep apnea, bruxism or acid reflux disease is present. FM is modified by hormonal, cytokine, neurotransmitter, and autonomic influences. The overwhelming majority with FM have sleep disorders, with the alpha-delta abnormality being the principal pathology. Managing sleep pathology in FM appropriately ameliorates the symptoms and signs of the syndrome more than almost any other intervention.
  • 28 - Sleep and falls in the elderly
    pp 299-306
  • View abstract

    Summary

    Pain management is increasingly recognized as a contributor to therapeutic effectiveness across a broad range of medical conditions in terms of improved outcomes and patient satisfaction. This chapter describes the nature of pain, epidemiology of non-malignant pain and comorbid sleep problems in older adults and the bidirectional relationship between sleep and pain. It presents the recommendations for evaluation and management of persistent, non-malignant pain drawn from evidence-based guidelines enhanced with emphasis on sleep. Pain has been associated with increased risk for depression, activity limitation or disability, polypharmacy, poorer quality of life, and increased healthcare utilization. Guidelines based on available evidence, supplemented with expert consensus, provide a framework for assessment and treatment of persistent pain in older adults. Optimal management strategies for the older adult with persistent pain include several goals such as identifying and treating primary sleep disorders, optimizing pain management and identification and treatment of psychiatric co-morbidities.
  • 29 - Dreaming and dreaming disorders in the elderly
    pp 307-318
  • View abstract

    Summary

    This chapter reviews evidence regarding the connections between sleep and specific common psychiatric disorders, as well as potential treatment approaches. These associations are particularly relevant in older adults, given the high prevalence of both sleep and psychiatric disturbances that accompany aging. Patients who are taught the principles of cognitive behavioral therapy (CBT) may learn to apply them in the treatment of both anxiety disorders and insomnia. Both subjective sleep complaints and objective findings have been reported in elderly patients with anxiety and depressive disorders. A strong interplay exists between these underlying psychiatric disorders and sleep disturbances. Patients with depressive and anxiety disorders may complain of insomnia, while in turn insomnia may increase the risk of developing a psychiatric disorder. To address this interplay, treatment with either pharmacotherapy or psychotherapy may focus on both the sleep disturbances and mood or anxiety disorders to achieve optimal benefit.
  • 30 - Sleep medication and traffic safety in the elderly
    pp 319-324
  • View abstract

    Summary

    This chapter reviews the nocturnal sleep disorders associated with Parkinson's disease (PD). The most common sleep disorders in PD include insomnia, REM sleep behavior disorder (RBD), sleep apnea, restless legs syndrome (RLS), and periodic limb movement disorder (PLMD). The diagnosis of RLS in PD patients may be confounded by akathisia and nocturnal motor symptoms. The presence of diurnal variations of symptoms in RLS, and the feeling of inner restlessness without a sensory component in akathisia, may help to differentiate akathisia from RLS. The primary neurodegenerative process of PD, complex medication regimens, age-related changes in the sleep architecture, and co-existent sleep disturbances play an important role in the development of excessive daytime somnolence (EDS). Several objective and subjective diagnostic tools have been used for the diagnosis of EDS in PD patients. Deep brain stimulation (DBS) has become an important treatment option for PD patients with disabling motor complications and dyskinesias.
  • 31 - Geriatric psychopharmacology: an overview
    pp 327-331
  • View abstract

    Summary

    Sleep, cognition, and behavior have all been observed to change as a consequence of the normal aging process as well as the pathological processes that occur in Alzheimer's disease (AD). In the early stages of AD, it is quite possible that sleep disturbances that are occurring as a result of normal aging also exacerbate the cognitive and behavioral symptoms of AD. As the disease progresses, sleep disturbances associated with the pathological neurodegeneration characteristic of AD emerge, with further behavioral and cognitive consequences. Sleep disturbances in AD have been noted using many subjective and objective measures, and these sleep disturbances increase with the severity of dementia. Evidence of phase disturbance of the circadian rhythm in patients with AD comes from many different studies using several methods. A recent study demonstrated that treatment compliance with continuous positive airway pressure device (CPAP) could be achieved in patients with possible or probable AD.
  • 32 - Epidemiology of sleep medication use in the elderly
    pp 332-343
  • View abstract

    Summary

    This chapter reviews the clinical and polysomnographic features of elderly narcoleptic subjects, and considers co-morbidity and therapeutic issues. A number of narcoleptic patients are older than 40 at diagnosis, this being due either to mild disease severity or misdiagnosis, or diagnosis delayed until late-life expression of cataplexy, or narcolepsy lacking cataplexy. Knowledge about the co-morbid disorders in narcolepsy is important inasmuch as it may sometimes contribute to diagnosis and it may also bring some insights into the pathophysiology of narcolepsy. Among the most frequently associated diseases were parasomnias, sleep-related breathing disorders, sleep-related movement disorders, internistic diseases, neurological disorders, and psychiatric disorders. Moreover, various drugs, such as stimulants, antidepressants, and sodium oxybate used in narcolepsy have been tested in adult patients over a range of ages, but not specifically in elderly subjects.
  • 33 - Management of insomnia in the elderly: the efficacy and safety of non-benzodiazepine hypnotics
    pp 344-361
  • View abstract

    Summary

    This chapter summarizes the recent knowledge on diagnosis, etiology, and treatment of restless legs syndrome (RLS) in the elderly. In the elderly, the ability to express experienced bodily sensations verbally may be limited by the impact of co-morbid conditions such as cognitive impairment, speech disorders, or aphasic syndromes. A potential central role of iron pathology for the pathophysiology of RLS is indicated primarily by secondary forms of the disorder, i.e. iron deficiency, end-stage renal disease, and pregnancy. The dopamine precursor levodopa in combination with a dopa-decarboxylase inhibitor is an effective therapeutic agent with high tolerability and without serious side effects, also in patients with concomitant medical disorders. The most clinically relevant problem with dopaminergic drugs in treating RLS is the development of augmentation, a medication use-related increase of symptoms, which usually occurs after an initial improvement. In severe cases, augmentation demands a switch of medication.
  • 34 - Use of benzodiazepines in the aging population: do the benefits outweigh the risks?
    pp 362-370
  • View abstract

    Summary

    This chapter describes the pathogenesis, neurovegetative and olfactory functions, EEG activity, neuropsychological assessment, and treatment of rapid eye movement (REM) sleep behavior disorder (RBD). In RBD patient's polysomnographic (PSG) recording reveals intermittent or complete loss of REM sleep muscle atonia and excessive phasic electromyographic (EMG) activity during REM sleep. Multiple neural substrates, mainly located in the brainstem, contribute to REM sleep atonia and may be involved in the pathogenesis of RBD. Recent studies have examined various neurophysiological and neuropsychological functions in idiopathic RBD, in order to detect early signs of central nervous system (CNS) dysfunction associated with the REM sleep motor dyscontrol. Lewy body pathology begins in the anterior olfactory nucleus and in the lower brainstem nuclei, affecting olfactory and autonomic functions initially, and progressing rostrally to ultimately affect the cerebral cortex. Clonazepam is currently regarded as the treatment of choice for RBD, and it is ineff ective in only 10% of patients.
  • 35 - Use of psychotropic drugs in the elderly: effects on sleep architecture
    pp 371-383
  • View abstract

    Summary

    This chapter provides some guidance on how to manage sleep apnea in the elderly. It focuses on obstructive and central sleep apnea. Sleep disordered breathing includes obstructive sleep apnea (OSA), central sleep apnea including Cheyne-Stokes respiration (CSR), and sleep hypoventilation. The underlying mechanisms that promote the development of sleep apnea in the elderly can be classified into three broad categories, namely: (1) replication of the pathophysiology of sleep apnea in middle-aged adults; (2) physiological changes that are uniquely associated with aging; and (3) consequences of chronic medical disorders and/or medications. Elderly patients with sleep apnea can present with typical clinical features such as snoring, choking or gasping respirations, witnessed apneas, morning headaches, hypertension, and daytime sleepiness. After the identification and treatment of any underlying medical disorders that contribute to sleep apnea, such as hypothyroidism and acromegaly, weight reduction, and postural therapy can be considered.
  • 36 - Non-pharmacological treatment of insomnia in the elderly: cognitive behavioral therapies
    pp 384-393
  • View abstract

    Summary

    Obstructive sleep apnea (OSA), a frequent form of sleep disordered breathing (SDB), is associated with commonly occurring cardiovascular disorders, including hypertension, coronary artery disease, congestive heart failure. Central sleep apnea (CSA) is frequently associated with congestive heart failure (CHF). Cheyne Stokes respiration (CSR), a form of periodic breathing, commonly accompanies CSA patients with heart failure and portends increased mortality. This chapter explores these and other associations between sleep disorders and cardiovascular disease. SDB is highly prevalent in the elderly and the odds of having significant SDB are estimated at 1.79 per 10-year increase in age. The relation between insomnia and cardiovascular disorders has been less well examined than that between SDB and cardiovascular disorders, especially in the elderly. Large prospective studies will be needed to understand the association between insomnia complaints and coronary artery disease (CAD), and determine the direction of causality, if any.
  • 37 - Self-help treatments for older adults with primary and co-morbid insomnia
    pp 394-402
  • View abstract

    Summary

    This chapter addresses the age-related changes in sleep and the nature, assessment, diagnosis, and epidemiology of older adults with insomnia (OAWI) from a behavioral sleep medicine perspective. Complaints of insomnia are categorized into difficulty falling asleep, difficulty maintaining sleep, unwanted early morning awakenings, and non-restorative sleep often with daytime consequences such as excessive daytime sleepiness and fatigue. Factors that interfere with the opportunity to obtain sufficient sleep include other sleep disorders, substance use, shift work, or the presence of another psychiatric disorder. As one moves from middle age to the later years of life, the aging process creates changes in sleep architecture and continuity that increase the vulnerability to developing chronic insomnia. Research indicates that some crucial interventions that buffer against chronic insomnia may help the older adult to adopt a regular daily schedule, a healthier lifestyle and sleep behaviors, and increase the quality of social interactions and physical activity.
  • 38 - Complementary and alternative medicine for sleep disturbances in the elderly
    pp 403-412
  • View abstract

    Summary

    Sleep patterns of nursing home residents are extremely fragmented. This is manifested not only as disrupted night-time sleep, but also by frequent daytime sleeping. Poor sleep represents more than a mild annoyance for nursing home residents. Nursing home residents often suffer from multiple medical and psychiatric co-morbidities and are often in poor physical health. Circadian rhythm changes contribute to sleep problems in nursing home residents. Real change will require administrators and other staff to recognize that sleep is important and encouraging better sleep would benefit both residents and staff over the long term. Sleep disturbance is associated with negative outcomes among nursing home residents. While data to support the use of pharmacotherapy for sleep in the nursing home are limited, there is some suggestion that disturbed sleep improves with non-pharmacological treatments; however, these treatments have not been adapted for implementation into routine care.
  • 39 - Therapeutic benefits of napping in the elderly
    pp 413-422
  • View abstract

    Summary

    Poor nocturnal sleep is generally associated with daytime sleepiness regardless of the underlying sleep-disrupting condition. A number of studies have demonstrated that patients with insomnia may have significantly disrupted overnight sleep, and yet no significant objective daytime sleepiness as a consequence. Special consideration should be given to mood disorders in the elderly population, and in particular depression. A specific complaint of chronic fatigue could be associated with a relatively poorly defined host of conditions that includes chronic fatigue syndrome (CFS), fibromyalgia (FM), and chronic widespread pain (CWP). Important factors determining the need for treatment of excessive daytime sleepiness (EDS) include chronicity, severity, reversibility in response to adequate overnight sleep, resistance upon demand, impairment of daytime functioning, and danger of (self) injury. A correct diagnosis is an important step, and one must try to tease out the specific complaint, as the fatigue and EDS do not necessarily coincide.
  • 40 - Effects oflight on the elderly
    pp 423-430
  • View abstract

    Summary

    Falls are a serious problem among older adults because they are common, disabling, and sometimes fatal. This chapter provides an overview of the effects of aging on balance and falls, to explore potential mechanisms by which sleep disorders might affect balance and falls. The sleep disturbances of aging have the potential to be frequent but unrecognized contributors to balance disorders and falls. One of the most obvious mechanisms by which sleep disorders might contribute to falls is by reducing alertness and attention. Recent cross-sectional and prospective observational studies have confirmed an association between general sleep problems among older adults and falls. State-of-the art methods of research in sleep and in balance can be applied to future observational, physiological, and intervention studies. Multiple potential mechanisms are possible; transient and chronic effects of poor sleep on attention and alertness are the most likely direct consequences related to balance.
  • 41 - Neuroimaging of sleep in the elderly
    pp 431-440
  • View abstract

    Summary

    Dream recall decreases with the age of the dreamer in both home and laboratory dreams in both men and women. As the dreamer ages, characters in the dream decrease, the dreamer is less likely to be the center of the dream action, and there are more family characters in the dream report. Social interactions in dreams are more commonly aggressive then friendly and least common are sexual interactions. Aggressive social interactions decreases as the dreamer grows older, while other aspects of the aggressive interactions such as witnessing, victim-hood, and the effect of the sex of the dreamer all change with the age of the dreamer. The style of dreaming changes with the age of the dreamer with men getting more passive in their dreams while women appear to get more active. Disorders of dreaming and specific dream contents, like dreams of lost resources, may well have diagnostic significance.

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