Misconceptions continue in our understanding of sleep disorders in the elderly, complicated by age-related factors that affect sleep. Among recent findings is intriguing evidence about CPAP tolerance.

Sleep specialists have made great strides recently in educating the medical community and the general public about sleep disorders. Yet even though increasing numbers of physicians and patients understand the value of sleep studies and specific treatments, the growing elderly population is often ignored when it experiences sleep disorders.

A recent study by the National Sleep Foundation found that two thirds of older Americans say they have problems sleeping, but doctors have diagnosed only a small percentage of them. For many years, a prevalent misconception has been that older individuals are expected to have problems with sleep. When older relatives would routinely fall asleep during family gatherings, it was never questioned. The rest of the family would just chalk it up to Grandpa’s age. Furthermore, many physicians still blame sleep problems in the elderly primarily on chronic pain and symptoms resulting from other conditions, such as arthritis, stroke, heart disease, lung disease, diabetes, cancer, hypertension, or depression.

“Up to now, medicine’s approach to sleep disorders and the elderly has been to fix everything else first and then treat their sleep problems,” explains Helene Emsellem, MD, director of The Center for Sleep and Wake Disorders in Chevy Chase, Md, and Diplomate of the American Board of Sleep Medicine. “I don’t feel this approach is particularly healthy for these patients; in fact, waiting to the bitter end to address the sleep problem leaves the patient compromised.”

Emsellem cites a case in which an 86-year-old patient who was scheduled for abdominal aneurysm surgery complained about being sleepy most of the time. Several years ago, he had been diagnosed with sleep apnea but had difficulty using continuous positive airway pressure (CPAP) at night, so he stopped using it. Left untreated, his sleep apnea became worse and now he plans to undergo major surgery, which could lead to complications due to this severe apnea. As a result, Emsellem needed to address the sleep apnea again immediately prior to the scheduled surgery.

Holistic Approach
In the best interest of their elderly patients, The Center for Sleep and Wake Disorders takes a holistic approach when assessing and treating sleep disorders. “Research continues to show that sleep is critical for healing disease processes and for general well-being,” says Emsellem, “so it only makes sense to treat sleep disorders in the elderly just as we would treat sleep disorders in younger individuals.” In fact, Emsellem asserts that since the elderly typically have a greater number of health problems, they should be treated more aggressively for sleep disorders.

Adults need 71¼2 to 8 hours of sleep each night. As people age, their need for sleep actually stays the same or only decreases slightly (61¼2 to 7 hours a night). Sleep problems in the elderly can be caused by emotional stress, physiologic changes, adverse effects of medications, and frequently comorbid conditions. The National Sleep Foundation study found that between 71% and 82% of seniors with medical conditions reported sleep disorders; 84% of those with mobility problems reported sleep difficulties. Sleep specialists like Emsellem, however, are quick to point out that if a physician focuses only on treating the specific disease, such as arthritis, rather than treating the arthritis and the sleep disorder concurrently, the patient may sleep better without pain but may end up with an undiagnosed sleep disorder.

Sonia Ancoli-Israel, PhD, professor of psychiatry at the University of California San Diego School of Medicine and director of the Sleep Disorders Clinic at the San Diego Veterans Affairs Medical Center, says many medical professionals still incorrectly assume that problems with sleep are related to aging. “Most of the data suggest that sleep disorders do not have anything to do with aging,” says Ancoli-Israel. “Yet many older patients don’t report these problems because they feel they are a normal part of aging, and many physicians feel the same way.”

Different Sleep Patterns
One of the difficulties is that older people do experience changes in their sleep habits, and frequently this can lead to more serious sleep disorders. The National Sleep Foundation study confirms that older people develop different sleep patterns as they age. Seniors rarely sleep in on weekends, and about 65% of seniors said they wake up at night several times a week to go to the bathroom, which disrupts sleep patterns. Older adults find that more time is needed to fall asleep, and maintaining sleep continuity is sometimes difficult, since sleep becomes increasingly fragmented. As this occurs, the amount of time spent in deeper levels of REM sleep is decreased while more time is spent in lighter stages of sleep. Older individuals who have difficulty achieving deep sleep are usually more easily awakened by environmental stimuli, and their sleep is not as restful. Aging also affects the circadian rhythms, which can alter the timing of sleep. For example, many elderly people go to bed earlier in the evening and awaken earlier in the morning. Other factors contributing to these schedule changes include a lack of physical exercise, a lack of social/mental stimulation, sensory impairments, or too much time spent in bed.

Older people also have a greater likelihood of having comorbid conditions directly linked to nocturnal awakening, such as nocturia, trochanteric bursitis, orthopnea, and gastroesophageal reflux. These problems typically result in an increase in daytime sleepiness and napping, which brings about a polycyclic pattern in which several sleep-wake cycles occur within a 24-hour period.

Elderly individuals living in nursing homes have a greater number of sleep disorders due to that environment. “One of the problems with nursing homes is that there are usually not enough activities during the day to keep the patients occupied, alert, and active,” says Ancoli-Israel. “Often there is not enough bright light during the day and there is too much light coming from the hallways at night.” Noisy roommates and neighbors and nurses’ conversations keep many patients from sleeping soundly. “Studies show that if you can control the light, noise, and physical activity levels of the patients during the day, they would sleep much better,” says Ancoli-Israel.

Patients with dementia often have disturbances with their sleep/wake cycles, which can be challenging for caregivers or nursing home staff since the patients’ sleep rhythms do not always correspond with daily routines established by the caregivers or nursing home staff. In many of these instances, patients are prescribed hypnotic medications, which often lead to additional impairments with cognition.

The CPAP Factor
Ancoli-Israel studied this population closely by looking at the effect of CPAP on cognitive functioning in patients with mild to moderate dementia. This study found that those patients who were able to use CPAP experienced an improvement with their sleep apnea. “We’re hoping that by helping these patients with their sleep apnea, we may ultimately be able to help them improve their cognition or at least delay the decline of cognitive functioning,” says Ancoli-Israel. “In some cases, we may even be able to postpone institutionalization.” According to Ancoli-Israel, one of the interesting findings of the study was the large percentage of dementia patients who tolerated the CPAP effectively. Many physicians are still reluctant to prescribe CPAP for dementia patients because they think that they would become frustrated using the devices.

For the elderly apneic patients Emsellem treats, she prefers daytime desensitization followed by a nighttime CPAP titration study rather than split-night studies in the laboratory. “I think it’s very hard for elderly patients to sleep in the lab and then expect them to get used to CPAP when they’re having a hard time sleeping in a strange environment,” she says. If the patient is diagnosed with sleep apnea, the spouse or caregiver is asked to join the patient during the appointment to learn how to use the CPAP equipment. “We feel it’s very important to let elderly patients get used to the CPAP gradually before they use it for an entire night,” she says.

Emsellem points out that insomnia is an enormous problem for the elderly. She has conducted several research studies on insomnia, which have attracted older insomniac patients to her center. Many of these patients have medical conditions that contribute to the insomnia, but Emsellem stresses that the complaints need to be addressed concurrently. “In many instances, chronic psychophysiological insomnia will remain long after the primary medical condition is treated, so it makes sense to treat the problems synchronously,” she says.

Ancoli-Israel has also conducted extensive research on the elderly and insomnia and notes that there is a 30% to 50% prevalence rate for this population. Insomnia may result from medical, psychiatric, and drug issues; circadian rhythm changes; sleep disorders; and psycho-social factors. She adds that some patients incorrectly think they have insomnia. “Sometimes older patients think they have insomnia because they develop a pattern of taking a late nap and they can’t sleep well at night, and this is not insomnia.” In general, the treatment options for patients with insomnia are behavior modification and pharmacotherapy.

Limbs and REM
Elderly people also have a greater chance of experiencing periodic limb movements compared with younger individuals. Periodic limb movements in sleep are repetitive movements that typically affect the lower limbs and occur every 20 to 40 seconds. These movements consist of muscle twitches, jerking movements, or an upward flexing of the foot. The National Sleep Foundation reports that about 35% of people aged 65 and older experience periodic limb movements. Although not considered medically serious, periodic limb movements can be a contributing factor in chronic insomnia and/or daytime fatigue because they typically cause awakenings during the night.

“With patients complaining about limb movements, we usually perform a sleep study to make sure that apnea is also not present,” says Emsellem. She explains that if patients are diagnosed with periodic limb movements, they usually can be successfully treated with medications.

Increasing numbers of elderly patients are also being diagnosed with rapid eye movement (REM) behavioral disorder. Many individuals with degenerative brain stem diseases such as Parkinson’s disease experience this disorder. Instead of remaining virtually paralyzed during REM sleep, patients with REM behavioral disorder lose this paralysis and may act out their dreams, potentially injuring themselves or their bed partners. This disorder, when left untreated, also causes many patients to become institutionalized.

Exercise and Communication
A wide range of less serious sleep disruptions also affect elderly people. Some merely have difficulty sleeping soundly without having to get up and use the restroom. For these individuals, research has shown that physical exercise can help them sleep better at night. Results from a Stanford University study, which appeared in the Journal of the American Medical Association in January 1997, showed that when a group of individuals over the age of 55 performed regular physical exercise, they experienced an improvement in the general quality of sleep, quicker sleep onset, longer sleep duration, and feelings of restedness in the morning.

As the elderly continue to seek out care at sleep centers, the respiratory therapist will continue to play an important role in their treatment. Emsellem stresses that respiratory therapists who desire working with elderly patients who have sleep disorders should be both patient and flexible. It is important to show warmth and compassion when teaching them how to use equipment or handle their sleep problems. “Therapists must also be able to communicate well—not only with the patient, but also with the spouse, family member, or caregiver,” says Emsellem. In many instances, somebody else will be assisting the patient with their CPAP headgear, and they must understand how it works. Manufacturers also have made improvements in CPAP and bilevel positive airway pressure devices for elderly patients. Many of these devices are now more comfortable to wear, and some are designed to initially lower the expiratory pressure, which works well for this population.

Emsellem stresses that respiratory therapists also play a role in educating the medical community and the public about the prevalence of sleep disorders in the elderly. Through their involvement in professional organizations and their direct contact with physicians and nurses, they can inform people about the importance of treating these patients’ sleep disorders.

Emsellem also looks to the active elderly patients in her practice as role models for other older patients. She has many patients who seek out care on their own to remain healthy and vital. “We have a highly functional 82-year-old CEO who travels internationally at least 6 or 7 days a month and has a rigorous schedule when he is in town,” she notes. “Nothing slows him down, including any sleep problems.”

Carol Daus is a contributing writer for RT.