Age-related sleep disorders: you do not snooze, you lose

Highlights:

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• During aging, sleep inevitably changes due to the change in the circadian rhythm functionality, melatonin deficiency, and decreased homeostatic regulation
• The most common age-related sleep problems include insomnia, obstructive sleep apnea, movement, and sleep-wake cycle disorders
• Sleep disturbances increase the risk of multiple disorders, including cardiovascular disease, dementia, and depression
• Previously existing conditions, such as diabetes, can trigger sleep disorders, thus creating an unhealthy feedback loop
• Multiple strategies exist to correct sleep problems. They range from sleep hygiene to pharmacological solutions.

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Introduction: Poor sleep as a risk factor for the aging population 

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By 2030, it is estimated that approximately one in five people in the United States will be over the age of 65. The aging population requires addressing age-specific health issues to ensure that people live not only long but healthy. One of the prominent aging problems is changes in sleep physiology, leading to the emergence of sleep disorders. As many as 50% of older adults complain about insufficient sleep quality. Poor sleep can lead to a diversity of problems, such as impaired cognition, increased risk of cardio- and cerebrovascular disorders, and a higher probability of falls.

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As we age, our sleep patterns change

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During aging, sleep becomes progressively lighter with an increased number of awakenings, resulting in reduced sleep efficiency and lesser total sleep time (1). Compared to young adults, the elderly tend to go to bed and wake up earlier.

This shift in sleep architecture and time is linked to the changes in the circadian rhythm, which is controlled by a part of the hypothalamus called the suprachiasmatic nucleus (SCN). Aging leads to a decrease in the SCN sensitivity to environmental changes, leading to a 24-hour day/night cycle malfunction. 24-hour cycle malfunction leads to decreased quantity of deep sleep. Plainly, this means that elderly spend a lot of time sleeping, but the quality of sleep drops. The amplitude of circadian rhythms, including body temperature and cortisol levels, becomes less pronounced in the elderly due to changes in neural connections in the brain and decreased number of neurons (2, 3).

Another significant change is a decrease in melatonin levels – a sleep hormone produced by the pineal gland (a small gland located near the center of the brain). Melatonin production is linked to the circadian rhythm and is increased at night. However, with age, night-time production of melatonin diminishes, which may result from the calcification of the pineal gland itself (4).

Except for circadian regulation, sleep is also regulated by homeostatic processes. When an individual gets an insufficient amount of sleep, this loss is compensated by extending subsequent sleep (5). Research shows that aging decreases this regulative capacity, partially leading to the deficit in total sleep time (6).

All the above-mentioned changes are relevant to older adults in perfect health, which is rarely the case. If sleep disturbance stems only from such changes, it is called primary sleep disorder. Many elderly have multiple comorbidities, such as osteoarthritis, cardiovascular disease (CVD), diabetes, or cancer (7). These comorbidities, along with the increased use of medications (such as glucocorticoids or beta-blockers), can trigger further detrimental effects on sleep.

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Most common sleep disorders

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One of the most well-known sleep disorders in the elderly is insomnia. According to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, insomnia can be defined as “reported dissatisfaction with sleep quantity or quality, associated with difficulty with sleep initiation, maintenance, or early-morning awakening, that causes clinically significant distress or impairment, occurs at least three nights per week for three months, occurs despite adequate opportunity for sleep, and is not better explained by another disorder or substance abuse” (7). As indicated by studies, the prevalence of insomnia in the elderly population can be as high as 70% (8). However, there is a wide variation among different groups. Some reports indicate a higher prevalence of insomnia in nursing homes and rural areas (9,10). Also, there are prominent gender differences, with insomnia being generally more frequent in women (11).

The following common disorder is obstructive sleep apnea (OSA), characterized by instability of the upper airway during sleep, which results in reduced or absent airflow (12). OSA prevalence in older adults may reach 70% in men and 56% in women (13).

Movement sleep disorders include restless legs syndrome (RLG, also known as Willis-Ekbom disease) and rapid eye movement sleep disorder (RBD). RLG is linked to unconscious leg movements accompanied by abnormal sensations and sleep maintenance problems (14). The exact pathogenesis of RLG is unknown but might be related to dopamine dysregulation. RLG prevalence in older people can reach around 35%. RBD is a condition that occurs during the fast (rapid eye movement) stage of sleep when affected people display a variety of movements, like talking, shouting, or thrashing limbs. The etiology of RBD is also unclear, but it is most prevalent among older males (15).

Altered circadian rhythm leads to multiple sleep-wake disorders, the most common among older adults being advanced sleep-wake phase schedule (ASWPS) disorder (16). With ASWPS, individuals tend to become sleepy between 7 and 8 PM and wake up between 3 and 4 AM (the time where sleep is supposed to be the deepest), which can result in insufficient sleep quality. ASWPS frequently gets misdiagnosed as insomnia, but the treatment approach for it differs.

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Sleep disorders and consequences 

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The danger of sleep disorders lies not only in the discomfort from lack of quality sleep but also in the consequences for overall health. Research suggests that lack of sleep is strongly linked to increased mortality (17). 

Multiple reports have found an association between sleep disturbances and increased incidence of CVD. A study in a Japanese population demonstrated that long sleep duration combined with poor sleep quality correlated with a higher mortality risk due to CVD (18). Similar tendencies were observed in aged American Indians suffering from insomnia (19). OSA was associated with an increased risk of ischemic stroke.

Another risk connected with sleep disorders is various types of dementia. In their meta-analysis, Shi et al. (20) analyzed the influence of various sleep disorders. The authors concluded that sleep-disordered breathing, like OSA, was a risk factor for all-cause dementia, Alzheimer’s disease, and vascular dementia. By contrast, insomnia increased only the risk for Alzheimer’s disease. Moreover, sleep-disordered breathing in middle age can serve as an accurate predictor of the development of dementia later in life. Chronic RBD has also been associated with neurodegenerative disorders like Lewy body dementia and Parkinson’s disease (21).

Sleep disorders, quite expectedly, are linked to multiple mental health and cognitive issues common in the aged population (22). Anxiety and depression are widely spread in the elderly and can result from changes in sleep physiology. Usually, sleep changes are regarded as secondary to depression. However, recent studies indicate that sleep disorders precede the occurrence of depression and increase its risk in the long run (23).

Treatment strategies

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An approach to treatment depends on the specific sleep disorder (16). Treatment of insomnia must include a thorough management of a regular sleep-wake schedule, optimizing treatment of comorbidities, and (if possible) elimination of medicines contributing to the condition. Cognitive therapy has shown robust improvements as a first-line treatment (24). Pharmacotherapy is widely applied but should be exercised with caution in the elderly due to the multiple side effects. The main used classes of drugs, such as benzodiazepines, can lead to adverse effects, such as drug dependence, rebound insomnia, and tolerance when on prolonged use (25). Non-benzodiazepines carry a lower risk but still might lead to an increased risk of falls or worsening cognitive impairment. Melatonin supplements, herbal remedies (such as valerian), and musical therapy are widely applied, though their application is not regulated by FDA. Natural sunlight exposure, especially sunset, can also be beneficial due to the prevalence of the red tones, which stimulate the pineal gland and improve sleep.

OSA can be improved by applying continuous positive airway pressure therapy, which was shown to improve cognition, memory, cardiovascular condition, and sleep in the elderly. A promising approach could be also a hypoglossal nerve stimulation, such as Nyxoah, with clinical trials being carried out. Movement disorders usually are treated with benzodiazepines or melatonin, while circadian rhythm disorders are best tackled by bright light therapy.

Besides listed treatments, non-pharmacological management might be most beneficial as the first-line approach for older patients. Regular physical exercise is a simple strategy because it promotes relaxation, which could help initiate and maintain sleep. Another essential strategy is maintaining proper sleep hygiene by controlling the schedule and sleeping conditions.

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Tips for professionals

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• Assess the individual sleep quality if the client has complaints such as chronic fatigue. Propose the client to use a simple sleep quality checklist marking daily activity, caffeine intake, sunlight exposure, food before bed, etc.
• Inform your client about possible physiological reasons for the sleep disturbances while considering their accompanying health problems. Explain the risks connected with insufficient amount and quality of sleep.
• Suggest starting with simple steps by improving their sleep habits and tracking the changes in sleep quantity and quality. Wearables, such as smartwatches and sleep trackers, are one of the most convenient tools for monitoring sleep quality.
• Melatonin supplements or herbal products may be one of the safer options to try.
• If your client’s condition allows, suggest introducing a simple exercise routine two hours before sleep.
• In case of severe disturbances, recommend a specialist who can advise on pharmacological treatment.

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Conclusions: sleep maintenance 

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Sleep disturbance in the elderly requires consideration of multiple risk factors and an individual approach toward treatment. Changes in sleep patterns are a part of the aging process, but they must be treated individually to minimize the damage. Sleeping well can improve overall condition, and a proper approach to sleep hygiene and maintenance is inseparable from a healthy and long life.

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References

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