1. Sleep Problems in the Elderly – Epidemiology and Impact Sleep complaints are common in older adults –70% experience ≥1 symptom of insomnia 1 –Most common symptom is difficulty maintaining sleep 1 –35% of individuals aged ≥65 years report nightly awakenings 2 Insomnia has significant effects on daily lives of elderly –Impairments in problem solving and in working and episodic memory 3 Risk factor for cognitive decline and increases risk of falls 4 1.Jaussent I et al. Am J Geriatr Psychiatry. 2011;19(1):88-97. 2.Ohayon MM. J Psychiatr Res. 2008;43(1):48-54. 3.Fortier-Brochu E et al. Sleep Med Rev. 2012;16(1):83-94. 4.Kamel NS, Gammack JK. Am J Med. 2006;119(6):463-469.

2. Primary Sleep Disorders in the Elderly 1.Eckert DJ, Malhotra A. Proc Am Thorac Soc. 2008;5(2):144-153. 2.Sforza E, Roche F. Frontiers in Neurology. 2012;3(87). 3.Lurie A. Adv Cardiol. 2011;46:1-42. 4.Hornyak M et al. Sleep Med Rev. 2006;10(3):169-177. 5.Gagnon J et al. Frontiers in Neurology. 2012;3(82):1-5. 6.Sack RL et al. Sleep. 2007;30(11):1484-1501. DisorderPrevalenceRisk factors Obstructive sleep apnea 1-3 Adults:2%–4% Elderly:24%–62% Obesity, age, male sex Periodic leg movement in sleep / periodic leg movement disorder 4 Adults:4%–11% Elderly:>35% Age, psychoactive substances REM sleep behaviour disorder 5 General:0.5% Elderly:7% Age, male sex, alcohol withdrawal Advanced sleep phase disorder 6 Middle-aged:7.4%Age, genetics REM = rapid eye movement

3. Factors that Adversely Influence Sleep Quality in Older Individuals Behavioural and environmental factors Physical status Sleep hygiene Extreme temperature Noise or light Lack of exposure to sunlight Physical inactivity Cardiovascular disorders Pulmonary diseases Gastrointestinal disorders Genitourinary disorders Neurodegenerative disorders Stroke and seizure Chronic pain Thyroid disorder Diabetes Menopause Psychosocial factorsMedication and drugs Stress Hyperarousal Social isolation Bereavement Change of residence Hospitalization Work status Alcohol Caffeine Nicotine Central nervous system stimulants Beta-blockers Thyroid hormones Calcium channel blockers Decongestants Bronchodilators Corticosteroids Anticholinergics Antidepressants Psychiatric disorders Depression Anxiety Psychosis Delirium Schizophrenia

4. Sleep Changes are Normal with Aging Changes in sleep schedule 1 –Earlier bedtimes and wake-up times –Increased daytime sleep (naps) –Reduced nighttime sleep Changes in sleep architecture 2 –Less sleep efficiency –Lighter sleep Changes in specific waves during non-REM sleep –Fewer slow waves ( 75 uV) and spindles (11–15 Hz), along with a decrease in their amplitude 3,4 1.Billiard M, ed. Sleep Physiology, Investigations, and Medicine. New York (NY): Kluwer Academic/Plenum Publishers; 2003: 297-332. 2.Ohayon MM et al. Sleep. 2004;27(7):1255-1273. 3.Carrier J et al. Eur J Neurosci. 2011;33(4):758-766. 4.Martin N et al. Neurobiol Aging. 2012 July 16. [Epub ahead of print]

5. Contributing Factors to Age-related Sleep Changes Caffeine Menopause Enhanced sensitivity to stress

6. Evaluation 1.Establish whether the sleep problem is insomnia or due to the normal aging process 2.Define the dominant sleep disturbance 3.Ask about napping habits and daytime sleepiness 4.Question the bed partner, where possible 5.Identify any medical conditions that may contribute to the patient’s disturbed sleep 6.Review your patient’s prescription/nonprescription medications 7.Ask about daily caffeine and alcohol consumption 8.Evaluate the patient’s stress and anxiety level and history of psychiatric and mood disorders 9.Consider referral to a sleep specialist should there be any suspicion of a primary sleep disorder

7. Management – Pharmacological Disproportionately high prescription rate in older adults –Hypnotic use: 3%–21% men and 7%-29% women ≥65 years 1,2 Prescription rates 3 –Benzodiazepines: 61% among women and 52% for men –Z-drugs (zolpidem and zopiclone): ~25% for women and men Elderly more vulnerable to hazards and adverse events 1,4 Melatonin –Results are inconsistent in younger and older patient groups 5 1.Staner L. Sleep Med Rev. 2010;14(1):35-46. 2.Maggi S et al. J Am Geriatr Soc. 1998;46(2):161-168. 3.Jaussent I et al. Am J Geriatr Psychiatry. 2011;19(1):88-97. 4.Lichstein KL et al. Sleep Med Clin. 2006;1(2):221-229. 5.Billiard M, ed. Sleep Physiology, Investigations, and Medicine. New York (NY): Kluwer Academic/Plenum Publishers; 2003: 297-332.

8. Management – Nonpharmacological Cognitive behavioural therapy –Recommended in the elderly –Sustained improvements in sleep over time 1 Phototherapy 2 –Mixed results for insomnia in the elderly 1.Morin CM et al. JAMA. 1999;281(11):991-999. 2.Friedman L et al. J Am Geriatr Soc. 2009;57(3):441-452.

9. 1.Don’t panic. Age-related sleep changes are normal unless you feel a negative impact on your life. 2.Discuss sleep difficulties with your doctor and let him/her know if you suspect that you have a primary sleep disorder or if your medical/mental condition interferes with your sleep. 3.If your night sweats or hot flashes interfere with your sleep, discuss it with your doctor. 4.Discuss possible adverse events associated with your medications. 5.Adopt a regular sleep-wake cycle and sleep a sufficient number of hours every night. Older people may have more difficulty recovering following sleep deprivation. 6.Try to stay away from night-work. 12 Recommendations for Elderly Patients to Sleep More Soundly

10. 7.Reduce drug and stimulant intake, especially caffeine, nicotine, and alcohol. 8.Create an optimal environment for sleep, including a quiet and dark room and a comfortable ambient temperature. 9.Diminish stressful experiences and worries at bedtime as much as possible. 10.Don’t eat too much or exercise near bedtime. 11.A daytime walk with correctly timed daylight exposure is useful for insomnia. 12.Be active, eat well and exercise: good health is strongly associated with good sleep. 1 12 Recommendations for Elderly Patients to Sleep More Soundly (cont.) 1.Reid KJ et al. Sleep Med. 2010;11(9):934-940.