Sleep and Aging Well The information in this publication was independently developed by the National Sleep Foundation. © 2003 National Sleep Foundation

Sleep and Aging How does sleep change as we age? Do we need less sleep as we get older? Can a person expect to experience more sleep problems or have a sleep disorder as they advance in age? As we age, how does sleep affect our overall health, medical conditions and general well being? What can we do to get good sleep? As our aging population increases, so do their concerns and experiences with sleep problems and disorders. Along with the body and brain changes that occur as we age, sleep also changes as part of the normal aging process. Many older people want to know how much sleep they need, how to sleep better and the signs and symptoms of sleep disorders. This program will address these questions as well as some of the common myths about sleep and aging. It will cover basic sleep physiology, sleep patterns, habits and quality of sleep along with the sleep changes that occur in the normal aging process. In addition, it discusses the association of sleep with health and disease, the importance of sleep to the lives of aging persons and provides an overview of the sleep disorders that become more prevalent as we age. Lastly, it provides some practical tips that help address sleep problems, when to seek help and how to get a good night’s sleep.

Sleep is Essential to Our Overall Health and Well-Being Key to our health, performance, safety and quality of life As essential a component as good nutrition and exercise to optimal health Essential to our ability to perform both cognitive and physical tasks, engage fully in life and function in an effective, safe and productive way Sleep is a biological requirement. All animals sleep. It is the… Key to our health, productivity, safety and quality of life It is an active process that energizes and restores our brain and body. In order to function and live at our best, sleep is as necessary as the water we drink, the air we breathe and the food we eat. Getting enough uninterrupted and restorative—or quality sleep— throughout the night prepares you for the daytime – the other 2/3’s of your life. Sleep gives you the potential to thrive and makes it possible to live a full life. It becomes… Essential to your ability to perform both cognitive and physical tasks at your peak, engage fully in life and function in an effective, safe and productive way

Normal Sleep and Normal Aging: Our Internal Clock The biological clock resides in the brain It helps regulate when we feel sleepy and when we are alert It works in tandem with light and dark, and our body temperature and hormones Sleep is part of a 24-hour cycle called a circadian (from the Greek words: “circa” =about and “dias”=day) cycle. This cycle is controlled by a biological clock in the brain and in part by bright light, melatonin and body temperature. Melatonin is a hormone, produced in the brain during darkness, that makes us sleepy. When light enters the eye, melatonin production is inhibited. Body temperature drops at night and that is when we get sleepy. The darkness, the melatonin and the temperature drop all contribute to sleep. Typically, there is a balance of sleep and alertness whereby we are most alert throughout the day except for an afternoon dip when we tend to feel sleepy and then the sleep drive becomes stronger toward the evening and is at its peak between 2–4 am. As we age, the circadian rhythm may be altered and advanced so that an older person may get sleepy and go to bed earlier in the evening. This may be followed by an early awakening— around 3–5 am— when the older adult may become alert, and finds it difficult to get back to sleep. A consequence of this shift may be daytime sleepiness and the urge to take naps during the day. Because light and dark cues help regulate our biological clock, light therapy is sometimes used to train a person to a later sleep schedule. Exposure to light during the morning helps keep you alert and increases the need for sleep in the evening. Exposure to light in the early evening moves bedtime later and allows you to sleep longer into the morning.

The Sleep Cycle in Adults Awake 1 2 REM REM REM REM REM Stages 3 4 Sleep occurs in stages. There are 4 stages of NREM or Non-Rapid Eye Movement sleep and one stage of REM or Rapid-Eye Movement sleep. NREM Stage 1 sleep is the onset of sleep with Stages 2, 3 and 4 becoming progressively deeper. REM sleep, also known as dream sleep, first occurs about 90 minutes after sleep onset. The eyes dart back and forth during REM sleep, thus, the name rapid eye movement sleep. Brain waves, which can be measured by an overnight sleep study, alter during each stage. Most of the deep sleep occurs in the first third of the night and most of the REM sleep is experienced in the last third of the night. All stages of sleep are important. Sleeping throughout these stages is important because this is when tissue growth and repair occur, energy is restored, and learning or memory is consolidated. 0 1 2 3 4 5 6 7 8 Hours in Sleep

Normal Sleep and Normal Aging: Less Deep Sleep As we age, our brain waves change and we tend to experience less deep sleep. Less time is spent in stages 3 and 4 while there may be longer periods of stage 1 and 2 sleep. In fact, stage 1 sleep can increase as much as 8-15%. Most studies also demonstrate an overall decline in REM sleep. The change in sleep architecture that occurs is associated with the aging process, but the disruptions in sleep are likely due to the impact of medical or psychiatric conditions.

Health and Environment Affect Our Sleep With age, we become more sensitive to: Hormonal Changes Physiological Conditions Environmental Conditions Light Noise Temperature As we age, the secretion of hormones is altered. We release less growth hormone, which normally is secreted during deep sleep and is particularly important to our muscles and tissue. The release of cortisol, that normally helps us become alert in the morning hours, increases in the evening around the 5th decade of life. Around or during menopause, women’s estrogen levels decrease and hot flashes occur. As a result, skin temperature rises and women may experience increased heart rates and sweating that disrupts sleep. A key sleep-promoting hormone, melatonin, is often released in the evening during darkness. As we age, we may not produce as much melatonin, and this makes it more difficult to fall asleep. In addition, the physical changes associated with chronic medical conditions such as arthritis and other musculoskeletal problems, gastrointestinal problems such as heartburn and any pain add to the litany of sleep disruptions that can occur as we age. Medications taken for the symptoms of these conditions may also lead to difficulties sleeping. Older people are also more sensitive to environmental factors, particularly if they have more light sleep. While noise, light and temperature may have minimally affected us as young adults, these factors have a greater impact on our sleep, causing arousals and further disruptions as we age. Older people are generally less tolerant to shift work and jet lag. Such fragmented sleep means less continuous, efficient and deep sleep resulting in daytime sleepiness and an inability to perform well during the day and experience a quality of life.

Normal Sleep and Normal Aging: Sleep Efficiency Changes with age (% Time in Bed Sleeping) Sleep Efficiency As a result of all of these physiological, hormonal, and environmental changes, older persons tend to sleep less efficiently. While they may be in bed 8 hours, at 55 years of age and older, both men and women may be in actual sleep for just 7 hours or less. Frequent disruptions or poor sleep robs the older person of the continuous sleep necessary to experience the deeper stages of sleep and reap their benefits. Men Women Age

The ability to get continuous and consolidated sleep may become more difficult as we age Although many older adults need as much sleep as when they were younger, due to bodily and brain changes in normal aging, it often becomes more difficult to get sufficient, continuous quality sleep. In one study, total sleep time decreased 27 minutes for each decade from mid-life into the 8th decade. Older adults may need to meet their sleep needs differently.

Sleep Problems/Disorders Prevalent Among Older Persons SYMPTOMS OF SLEEP PROBLEMS BY AGE Symptoms: a few nights a week or more 55-64 65-74 75-84 Insomnia 49% 46% 50% Snoring 41% 28% 22% Sleep Apnea 9% 6% 7% Restless Legs Syndrome (RLS) 15% 17% 21% This list represents the most common sleep disorders that are prevalent as we age.

Insomnia A perception or complaint of inadequate or poor sleep Difficulty falling asleep Frequent awakenings Waking too early and having difficulty falling back to sleep Waking unrefreshed A highly prevalent condition affecting as many as 48% of older persons Next day consequences Insomnia is a highly prevalent sleep problem among older adults. According to the 2003 NSF Sleep in America poll, 48% of older persons experience any or all of these symptoms at least a few nights a week or more. And the incidence of insomnia increases 5% as we age. Although it is most common to have difficulty maintaining sleep as we age, older persons may also have difficulty falling asleep, experience frequent arousals and awakenings and/or wake feeling unrefreshed. When talking to your doctor about insomnia, what’s important is to first look together to determine if there is an underlying cause such as a medical or psychiatric condition. Insomnia can be acute due to a short-term or temporary situation such as a loss in one’s life (e.g. a job or death of a loved one), or a change such as a move, divorce, or hospitalization, or it may be due to temporary stress – even something positive such as a long awaited trip or a new grandchild. Chronic insomnia—lasting for over one month —may arise from a medical or psychiatric condition, and when treated, its symptoms may be alleviated. For some people and when there is no known underlying condition, insomnia can become primary as well as chronic. Untreated insomnia can take a serious toll on one’s life and sufferers often experience sleepiness during the day, difficulty concentrating, trouble completing tasks, drowsiness while driving, an increased risk for accidents and illness and a general inability to enjoy a good quality of life.  

Insomnia (continued) Effective Treatment Healthy sleep habits Behavioral therapy Prescription hypnotic medications Other therapies Effectively managing insomnia often consists of a one or a combination of the following: establishing healthy sleep habits, behavioral therapy learned from a trained professional, prescribed medications and other therapies: As we age, establishing and practicing healthy sleep habits will contribute to getting a good night’s sleep throughout our lives and good sleep hygiene will become an essential component of any treatment plan for improving sleep. These are described in greater detail in this program, but a key to good sleep includes maintaining a regular sleep schedule, creating a conducive sleep environment and incorporating healthy habits into your lifestyle. Behavioral therapies can be learned from a trained professional and generally involve helping people to associate the bed with sleep, restricting time in bed to only when sleepy, relaxation training, reducing anxiety and developing positive attitudes about sleep. Hypnotics are the drug class of choice because they have proven effective in hastening sleep onset, reducing the number and duration of awakenings and/or improving overall self-reported sleep quality. They also have fewer side effects. Among other considerations, it is important to prescribe the appropriate dosage to the age of the patient. Although there is evidence that women tend to sleep better overall, they demonstrate a higher use of hypnotics. Other therapies that have been used to treat insomnia include melatonin, valerian and herbal products. Although melatonin may be helpful for falling asleep and under certain circumstances such as jet lag, there is no conclusive evidence as to its safety and effectiveness, especially for long-term use. Because there has been no rigorous testing of these products, there are no regulations regarding the manufacturing or prescribing of products that are sold as OTCs or in health stores.

Snoring Partial blockage of airway causing abnormal breathing and sleep disruptions 90 million; 37 million experience on a regular basis Males Those who are overweight and with large neck size most at risk Loud snoring can be a symptom of sleep apnea Snoring is a breathing noise that occurs during sleep and can be very disruptive to you or your bed partner. While breathing in, the air passage between the upper soft palate and the throat or base of the tongue opens and closes. As muscles relax, there is a partial obstruction to the air passage - the area colored orange in the diagram - causing the tissues to vibrate and make the snoring noise. This abnormal breathing that causes sleep disruptions affects approximately 90 million American adults; 37 million on a regular basis. Persons most at risk are males and those who are overweight. It often increases with age.  Loud snoring is particularly serious as it can be a symptom of sleep apnea and can be associated with high blood pressure and other health problems.

Sleep Apnea Increases as we age: affecting 4% and 2% of middle-aged men and women and close to 27% and 19% of older men and women Characterized by pauses or gaps in breathing due to an obstruction of the airway Sleep apnea is a serious sleep disorders that is most often diagnosed at a sleep center by an overnight sleep study. It becomes increasingly prevalent as we age, affecting 18 million Americans. It is more common in men, affecting 4% of middle-aged men and 2% of middle-aged women. Older men and women may even experience more episodes of apnea. Persons with sleep apnea experience an obstruction in the airway at the back of the throat during sleep. This is a breathing abnormality that occurs during sleep, and in general, such breathing problems increase with age. In sleep apnea, air is blocked, breathing pauses—sometimes for longer than 60 seconds—and oxygen levels drop. This event alerts the brain, causing an arousal and breathing resumes. Snoring often accompanies such events. As many as 20-60 of these events can occur in an hour, causing multiple sleep disruptions throughout the night, poor sleep and eventual daytime sleepiness.  

Sleep Apnea (continued) Signs and Symptoms Loud, regular snoring Large neck size Obesity Associated with major medical conditions Most common treatment CPAP For younger and middle-aged adults, having a large neck size and being overweight puts you at risk for apnea. If you experience snoring on a regular basis and it can be heard from another room, this is a sign that you might have sleep apnea and it should be discussed with your doctor. The incidence of sleep apnea increases with age. Because apnea can vary in severity, its treatment varies accordingly. However, untreated apnea puts a person at risk for cardiovascular disease, headaches and depression. The most common and effective treatment for sleep apnea is the use of a CPAP (continuous positive airway pressure) mask, like the one shown above, that forces air through the pathway and allows the person to breath and sleep well. Staying off one’s back while sleeping and the use of a special dental appliance may also be helpful. In addition, behavioral changes such as losing weight and avoiding alcohol, nicotine and sleeping medications can contribute to a reduction in the number of apneic events.

Restless Legs Syndrome/ Periodic Limb Movement Disorder Neurological movement disorders Involuntary urge to move due to unpleasant feelings in the legs during sleep or rest Jerking of legs and arms during sleep Increases with age Treatment Medications Healthy lifestyle Sleep hygiene Both restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) are neurological movement disorders that are bothersome and characterized by an irresistible urge to move the limbs. In RLS, unpleasant, tingling, creeping or pulling feelings occurring mostly in the legs, are worse in the evening and make it difficult to fall asleep. Its prevalence increases with age and about 12 million people experience RLS symptoms. About 80% of people with RLS also have PLMS and experience involuntary jerking of the legs and, sometimes, arms during sleep, making it difficult to get a continuous night of sleep. One study found that approximately 45% of older persons have at least a mild form of PLMS. Many people with these disorders also report insomnia and daytime sleepiness. Treatment of RLS and PLMD involves prescription medications, often with dopaminergic agents or agonists. Treatment may also include iron, vitamin or folate therapy, and developing good health and sleep habits including avoidance of alcohol and nicotine, regular exercise and establishing a regular sleep-wake schedule. In the older adult, it is important to watch for side effects as well as interactions with other drugs.

Medical Conditions Increase with Age Medical Conditions increase with age and are often associated with sleep problems and disorders Hypertension and Heart Disease Heart Failure Stroke Menopause Cancer Gastrointestinal Disorders As we age, there is an increased incidence of medical problems that are often chronic. In general, people with poor health or chronic medical conditions have more sleep problems. One study indicated that of those who are diagnosed with a medical condition, 80% reported chronic insomnia within three years of diagnosis. Symptoms of medical conditions, the discomfort and pain, and their treatment often cause sleep disruptions or difficulty sleeping. Not only are they often an underlying cause of sleep problems and disorders, but sleep disorders are also often associated with some of these medical conditions. For example: Hypertension is often associated with both snoring and sleep apnea - both increasing as we age. Continuous apneic events put a strain on the heart and the accompanying breathing problems cause restless nights. Daytime sleepiness has been associated with cardiovascular disease; particularly for women whose fatigue during the day puts them at a 66% chance of developing cardiovascular disease. Heart failure is a highly prevalent condition, affecting approximately 5 million Americans. As many as 50% of people with heart failure also have sleep apnea. The frequent arousals affect cardiac function, often making the condition worse. Treatment with CPAP may reduce these symptoms. Those who have experienced a stroke are also more likely to be sleepy during the day and to have symptoms of insomnia. Menopause, with its accompanying hot flashes, changes in breathing and decreasing hormonal levels can lead to many restless nights. These symptoms, especially when combined with an increasing incidence of snoring and sleep apnea, can also contribute to nighttime problems. In persons with cancer, recent studies indicate that up to 50% of those recently diagnosed experience sleep problems; 75% of those undergoing chemotherapy or radiation therapy report less efficient sleep and the resultant fatigue during the day that makes it difficult to carry out daily activities. In addition to the anxiety of the diagnosis, pain and treatment negatively impact on getting a good night’s sleep and experiencing a quality of life. Gastrointestinal problems, such as heartburn often leading to GERD or gastroesophageal reflux disease, cause difficulty both falling and staying asleep. Of heartburn sufferers, about 80% experience nighttime heartburn, causing discomfort and awakenings. GERD involves a reflux or a flow back of acidic gastric juices into the esophagus. This is more likely to occur while in the prone position.

Medical Conditions Increase with Age (continued) Medical Conditions increase with age and are often associated with sleep problems and disorders Alzheimer’s, Parkinson’s and cognitive problems Depression Arthritis Other conditions People who have dementia, are cognitively-impaired or suffer from such neurological diseases as Alzheimer’s or Parkinson’s, have demonstrated related sleep difficulties. Sleep-disordered breathing and daytime sleepiness are both associated with cognitive impairment. The amount of sleep disturbances in a person with dementia is often associated with the level of dementia. In fact, the sleep of people with dementia is so fragmented that they often do not experience a full hour of either sleep or wakefulness throughout a 24-hour period. Sleep-disordered breathing also occurs more frequently in those with Alzheimer’s disease. Both the duration and frequency of awakenings increase and persons with this disease experience less deep sleep overall. In addition, Alzheimer’s patients have worse sleep with cognitive and functional impairment. Those with Parkinson’s disease are more likely to have RLS symptoms. About 15% of older persons suffer from some form of depression, which can be associated with a family history, stroke, heart disease, cognitive impairment and socioeconomic stresses such as bereavement. Depression is most closely associated with insomnia; being a risk factor for having difficulty sleeping while poor sleep also contributes to depression. Both may also lead to daytime sleepiness as well as onset or recurrent depression in later life. It is estimated that 50% of people with depression have some type of sleep impairment. The pain and discomfort associated with symptoms of arthritis, and other musculoskeletal conditions such as back pain, makes it difficult to sleep through the night. Although older people seem to tolerate pain better, two-thirds of those with chronic pain report poor sleep quality. Frequent awakenings due to pain that can occur 20-30 times per hour and the inability to relax lead to poor sleep and eventual sleepiness during the day. Other conditions such as diabetes mellitus, renal failure, respiratory diseases such as asthma, and immune disorders are all associated with sleep problems and disorders. For example, a recent study reported that 50% of people with diabetes have insomnia. People with chronic bronchitis and asthma have difficulty both falling asleep and maintaining sleep.

Medications Can Also Cause Sleep Problems Older persons are more likely to take medications for chronic medical conditions and many of these can adversely affect sleep. Because metabolism slows down as we age, drugs stay in the body longer and older people may be more likely to experience side effects from drugs. It is also important to inform your doctor of all of the medications being taken as interactions among them may alter their effectiveness and lead to further problems. In one study, those who experienced a higher use of medications and were frequent users of the health care system tended to have poorer sleep. Antihistamines are over the counter (OTC) drugs, often used for colds or allergies that have sedating effects, but should not be used to promote sleep. Their effects may leave one drowsy in the morning. And they may contribute to forgetfulness and agitated behavior. Diuretics, corticosteroids and some antidepressants can lead to insomnia. Central nervous system stimulants and some drugs used for cardiovascular problems can make people feel drowsy. It is important to be knowledgeable about the name, purpose and side effects of each medication taken.

The Use of Alcohol, Caffeine and Nicotine Impacts on Sleep Although alcohol, especially close to bedtime, has been known to facilitate sleep, when it wears off, it tends to cause fragmented sleep. Both alcohol and caffeine have been associated with insomnia. Caffeine, as an ingredient in coffee, tea, soda and chocolate as well as in some bottled water, and nicotine are both stimulants and both have a negative effect on our ability to get a good night’s sleep. Caffeine affects each person differently, but can affect sleep when taken anytime after lunch. Nicotine, like alcohol, has its greatest effect during withdrawal, causing sleep disruptions. Some people who use tobacco also experience more nightmares and one recent study indicates that nicotine can disturb the brain’s ability to regulate breathing during sleep. When taken too close to bedtime or in the middle of the night, nicotine makes it difficult to fall asleep.

How To Enhance Your Sleep: Practical Tips for Good Sleep Establish a regular schedule with consistent bed and wake times Maintain a relaxing bedtime routine Create a sleep-promoting environment that is comfortable, quiet, dark and preferably cool In order to promote and maintain sleep sufficient for good health, the following tips are recommended for a healthy sleep lifestyle: Establishing a regular sleep schedule helps keep you in sync with your natural circadian clock and makes it easier to fall asleep and maintain sleep throughout the night. Close to bedtime, prepare with the same relaxing ritual every night. This should not include alerting activities, but rather doing something that is enjoyable like listening to the radio, reading or taking a hot bath. If you want to delay or make your bedtime later, expose yourself to brighter light in the early evening or engage in a participatory activity. Your bedroom should be sleep promoting. Older people are more sensitive to noise, light and temperature, so keep the sleep environment quiet, dark and preferably cool so that it is comfortable.

Sleep Tips (continued) Limit fluids and don’t eat too much close to bedtime Avoid caffeine, nicotine and alcohol too close to bedtime and even after lunch Exercise, but not within 3 hours before bedtime Limit fluid and eat healthy snacks before bed or you will need to make frequent trips to the bathroom. Eating too much leads to discomfort and possibly heartburn. Eating too little can leave you with hunger pangs. Practice good health habits for good sleep by avoiding caffeine, nicotine and alcohol, especially close to bedtime. Exercise, in general, can be sleep-promoting. However, it should not be done 3–6 hours before bedtime. Your body needs time to cool down and relax.

If You Have Difficulty Sleeping Limit time in bed Use your bed only for sleep and satisfying sex Avoid watching the clock Limit naps Don’t spend too much time in bed. The longer you stay in bed, the more disturbed sleep becomes. You should be in bed about 30 minutes longer than you want to sleep and only use your bed for sleep or sex. For example, if you want to sleep 8 hours, do not spend more than 8.5 hours in bed. If you have difficulty sleeping, either at the beginning of the night and within 15 minutes of going to bed, or if you wake in the middle of the night and can not sleep, get out of bed and go into another room. Do something relaxing until you feel sleepy again, but try not to make the environment too bright. Bright light tells your body it is time to wake up. Then, return to your bed when you feel sleepy. Opening your eyes to look at the clock forces you to wake up. In addition, if you focus on the clock when you cannot sleep, you may become anxious when looking at the time. If this happens, it is sometimes best to remove the clock. Naps can be helpful for daytime functioning, but they can also decrease the need for nighttime sleep. Taking a nap, especially close to bedtime, will decrease your drive to sleep and may make it difficult to fall asleep. Also, you may not need as much sleep during the night. Naps may be helpful before going on a trip when you need to drive for long stretches or if you are changing time zones. When taken appropriately, they can contribute to improved performance. If you need to nap, limit it to 20-30 minutes early in the afternoon to avoid going in to deeper stages of sleep, making it more difficult to become alert following a nap.

Keep a Sleep Diary to Identify Your Sleep Habits and Patterns If you find you have difficulty sleeping and/or have some of the signs of a sleep disorder, be sure to talk to your doctor. It is very helpful to complete a sleep diary for at least 10 days so that you can document your sleep habits, schedules, relevant health habits and any sleep problems you are having. This can then be taken to your medical appointment for discussion with your doctor. Most sleep problems are manageable and treatable. Sleep plays a vital role in your health. Addressing any symptoms of sleep difficulties with your doctor not only impacts on your health, but can also affect other medical conditions.

Seek Help From a Sleep Specialist and a Sleep Study Should your sleep problem persist after any underlying causes have been treated, it may be necessary to see a sleep specialist. Many sleep disorders are diagnosed with an overnight sleep study and other standard tests and procedures. Sleep centers are staffed by physicians and other health professionals who are trained in sleep medicine and can perform the necessary diagnostic tests and make treatment recommendations.

Summary: Sleep Changes Sleep during the night changes with increasing age: Less deep sleep and more lighter sleep More difficulty maintaining sleep due to arousals and awakenings Sleep is less efficient and more fragmented The internal biological clock shifts to earlier bed and wake times Older persons experience a higher prevalence of medical conditions and take more medications that interrupt sleep and are associated with sleep problems/disorders Older persons experience a higher prevalence of sleep disorders

Summary: Consequences of Sleep Changes Tendency to stay in bed longer to get a sufficient amount of sleep results in worse sleep More likely to take more naps to meet sleep need—may result in worse sleep Inadequate or poor sleep results in daytime sleepiness and fatigue Ability to function well, enjoy life and overall quality of life is affected

Summary: What you can do Learn about sleep Understand how your sleep changes and observe your habits and experiences Apply healthy sleep practices to your sleep style so that you get sufficient quality sleep Talk to your doctor about your sleep and see a sleep specialist if you experience chronic difficulty sleeping and/or have symptoms of sleep disorders

The National Sleep Foundation is an independent nonprofit organization dedicated to improving public health and safety by achieving public understanding of sleep and sleep disorders, and by supporting public education, sleep-related research and advocacy. 1522 K Street, NW Suite 500 • Washington, DC 20005 • 202-347-3471 • www.sleepfoundation.org • © 2003

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Reference Material (continued) Articles: Newman AB, Spiekerman CF, Enright P, Lefkowitz D, Manolio, Teri, Reynolds CF, and Robbins J. Daytime Sleepiness Predicts Mortality and Cardiovascular Disease in Older Adults. J Geriatr Soc (2000); 48: 115-123 Phillips B and Ancoli-Israel S. Sleep disorders in the elderly. Sleep Medicine 2 (2001); 99-114. Shochat T, Loredo J, and Ancoli-Israel, S. Sleep disorders in the elderly. Curr Treat Options Neurol (2001); 3(1): 9-36 Vitiello, MV. Effective treatments for age-related sleep disturbances. Geriatrics (1999); 54 (Nov): 47-52. Vitiello, MV. Effective Treatment of Sleep Disturbances in Older Adults. Clinical Cornerstone (2000); 2(5): 6-27 Youngstedt SD, Kripke DF, Elliott JA, and Klauber MR. Circadian abnormalities in older adults. J. Pineal Res (2001 Oct.); 31 (3): 264-72

Reference Material (continued) Books: Ancoli-Israel, Sonia. All I want is a Good Night’s Sleep. St. Louis: Mosby-Year Book, Inc, 1996 Bliwise, Donald L. Normal Aging (Chapter 3). Kryger MH, Roth T, and Dement WC (Eds.). Principles and Practices of Sleep Medicine. Philadelphia: W. B. Saunders Company, 1994 Other: National Sleep Foundation 2003 Sleep in America poll Leadership Congress on Sleep, Health and Aging Monograph, 2004 Sleep and Aging (Public Education Brochure), 1998 NIH Consensus Development Conference The Treatment of Sleep Disorders of Older People (Volume 8, Number 3), 1990 For more information, visit the National Sleep Foundation’s website at www.sleepfoundation.org