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Sleep Disorders Center, 1 Department of Neurology, and 2 Division of Pulmonary and Critical Care, University of Maryland, Baltimore.
Address correspondence to Steven M. Scharf, MD, PhD, University of Maryland Sleep Disorders Center, 685 West Baltimore St., MSTF 800, Baltimore, MD 21201. E-mail: sscharf{at}medicine.umaryland.edu
THERE are now numerous reports in the literature to support the high prevalence of sleep difficulties and excessive daytime sleepiness in elderly persons. However, as the saying goes, acknowledging the problem is just the first step. Currently, both the fields of Sleep and Geriatric Medicine are faced with the more difficult task of sifting through potential causes and assessing the impact of sleep problems in elderly people. Although sleep patterns appear to alter as we age, by far, in elderly people, most sleep problems are not the result of biologic shifts in circadian rhythmicity but rather result from increasing disease burden, medication effects, depression and anxiety, and limited mobility (1,2). These issues, along with changes in a person's living situation, make elderly nursing home residents even more vulnerable to sleep disorders. The large number of factors affecting sleep in elderly individuals creates a challenge for both the geriatrician and sleep specialist. Both specialists ponder similar questions such as: What is "normal" sleep in elderly people? What are the consequences of sleep difficulties in elderly people? How do we evaluate sleep, and when and how do we intervene? We were delighted that the Journal of Gerontology: Medical Sciences is publishing, in the same issue, three papers of direct relevance to the evaluation of sleep disturbances in elderly people. The three articles use a variety of methods to help unravel some of the important questions, often coming up with answers that are different and more complex than the "usual suspects" seen in younger populations.
As seen in the articles by Endeshaw and colleagues (3) and Martin and colleagues (4), evaluation of sleep problems among nursing home residents has benefited from unique methods for evaluating sleep patterns. These include the use of an actigraph, an accelerometer worn on the wrist for assessing motion, and behavioral observations of sleep. These methods allow for a way to observe sleep/wake patterns and daytime sleepiness in a natural setting without the intrusion of polysomnography (3,4). Although polysomnography still remains the gold standard for determination of most organic sleep disorders (e.g., sleep apnea, periodic limb movement disorder), the study by Endeshaw highlights the difficulties using laboratory-type sleep studies in this population. The difficulties noted by the authors include scoring sleep stages in individuals with neurodegenerative diseases and often having to use limited studies (e.g., no leg electrodes). Furthermore, the efficacy of polysomnography in elderly nursing home residents has not been extensively studied, and assumptions based on data drawn from younger populations may not necessarily be generalizable in elderly persons. Some questions that need to be considered include: Is the first night effect or amount of sleep disruption associated with polysomnography similar to that seen in middle-aged individuals or community dwelling elderly individuals? Is sleep disruption from the testing procedure the cause of poor sleep efficiency? The answer to these questions is important—especially when reporting changes in sleep architecture as a lower percent of rapid eye movement or decreases in slow-wave sleep associated with daytime sleepiness. Endeshaw and colleagues should be congratulated for including polysomnography in their study, for, despite the limitations, the study provides much-needed data regarding sleep parameters in elderly persons. Using different methodology, Hill and colleagues (5) compare interview results of hostel residents to an Internet survey. Although such surveys may have inherent biases, the mere fact that they had such a good response supports the use of computer and Internet-based data collection, even in the elderly community. It is, therefore, refreshing to see a variety of methods available to better understand the complexity of sleep disturbances in elderly people.
It is an all-too-common scenario for elderly patients and their physicians to feel that sleep problems are a normal consequence of aging and thus undeserving of evaluation. Indeed sleep parameters such as longer time to sleep onset or increasing waking episodes at night appear to increase with age (1). Sleep disorders such as sleep apnea are also very common in elderly people including nursing home residents (6). What is not known is the degree of severity needed for these sleep problems to produce any negative consequences. Research by Hill (5) and others help to verify the impact of sleep problems in elderly people. The authors report on the association of a very common problem of falls in elderly individuals with sleep difficulties. This work is made even more notable in that "poor sleep quality" as perceived by hostel residents remained significantly (OR 3.2, 95% CI 1.04–10.0) associated with falls, independent of more common risk factors such as poor vision and use of walking aids. An interesting side question will be to see what sleep changes or disorders drive one's perception of "poor sleep." When the physician is faced with a complaint of disrupted sleep, the evaluation of daytime sequela often focuses on daytime sleepiness and fatigue-related issues such as concentration problems. However, the tendency to fall may be a unique and important metric to add to the clinical evaluation in elderly persons. Interestingly, on the other side of the coin, when evaluating daytime sleepiness, Endeshaw and colleagues (4) found that only limited mobility and Mini-Mental State Examination correlated with daytime sleepiness, not the more traditional sleep measures such as total sleep time or wake after sleep onset. Even the severity of sleep apnea as measured by the Apnea–Hypopnea Index (AHI) failed to significantly correlate with these outcomes. The lack of an association with sleep apnea and excessive daytime sleepiness occurred despite sleep apnea being common in their study population with 43% of participants having an AHI 
15 per hour. Other reports have also shown little association with mild and moderate sleep apnea and daytime sleepiness in elderly study participants (7). This finding again reinforces the idea that sleep problems and sleepiness symptoms in elderly people require a broad approach looking into unique etiologies and consequences.
Last, as sleep disorders in elderly persons gain recognition, it is only natural for treating physicians to want to know how best to improve sleep quality or daytime sleepiness. It is apparent that sleep problems in elderly people, particularly among nursing home residents, are the result of many underlying disturbances. Thus any intervention needs to be multifaceted. This is particularly true in the nursing home situation when stimulation, environmental control, and light–dark cycling are often poorly regulated. It is all to common to enter a nursing home and witness residents snoozing in their "geri" chairs or wheelchairs, often for hours on end during the middle of the day, when they should be active. Previous studies in nursing home residents demonstrated that increasing daytime activities decrease daytime sleepiness (8). These findings were beautifully extended by Martin and colleagues who showed that, in nursing home residents, a multifactorial approach including regulation of light exposure, enforcement of good sleep hygiene measures, and waking stimulation led to improvement in sleep–wake rhythms compared with a nonintervention group (4).
Regarding the treatment of nocturnal sleep difficulties, there is a continued fear of the use of hypnotics in elderly patients. Interestingly, both hypnotics and sleep problems are associated with falls. As noted by Endeshaw and colleagues, it is difficult to know if sleep disruption is the real culprit with hypnotic use being a marker for sleep disruption, or the other way around. In the study by Hill and colleagues, there was no association between hypnotic use and falls. Endeshaw and colleagues even found improvement in some sleep parameters in participants who used hypnotics. These findings are consistent with the finding that, in the community-dwelling elderly person, the judicious use of hypnotics may be beneficial in treating sleep disturbances (9). Thus, selective use of hypnotics, where indicated in elderly individuals, deserves closer examination in the nursing home setting.
Conclusion
The articles presented in this issue of the Journal, as well as other recent studies, address many important questions. It is now clear that mere extrapolation of concepts derived from younger patient groups may not be applicable in elderly people. On the other hand, it is also encouraging that there are interventions that may improve sleep–wake functioning in older patients. It is hoped that physicians treating elderly persons as well as researchers in the field will begin to incorporate these lessons into their evaluation and management of this growing and increasingly important patient group.
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Received May 16, 2006
Accepted September 21, 2006
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