Clinical practice guideline on management of sleep disorders in the elderly

Abstract

INTRODUCTION Sleep disorders are common in the elderly. It is estimated that 40-70% of elderly experience chronic sleep problems. Higher rates of sleep problems are observed in those elderly with medical and psychiatric comorbidity. The comorbid disorders have additive effects on sleep disturbances, i.e. higher the number of comorbidities, higher the rates of sleep problems. Elderly subjects have initial insomnia, wake up earlier than usual, have higher time spent in bed, have nighttime awakenings, nap more, and have decreased total sleep as compared to younger adults. With increasing age lighter stages of sleep becomes more, whereas, REM and slow-wave sleep reduce; up to 6 years of age there is 2% decrease in slow-wave sleep every decade. Slow-wave sleep does not change much from 60 to 90 years of age. However, sleep efficiency, i.e. the duration of sleep relative to total time in bed, continue to decrease over time. Sleep in the elderly is fragmented, lighter and is characterized by episodes of arousals and awakenings. Certain changes in circadian physiology occur with age. They include sleeping before the desirable sleep and wake times, earlier clock hour of internal circadian time, alteration in the relationship between the internal circadian time and sleep, reduction in circadian amplitude, and reduced sensitivity to low to moderate light levels. Among the elderly, core body temperature, and cortisol and melatonin rhythms occur at an earlier time. The changes in sleep that occur with age are summarized in Table 1. However, these changes are not the common sleep complaints of the elderly population.Table 1: Sleep changes in the elderlyIndian Psychiatric Society (IPS) published Clinical Practice Guideline (CPG) for management of sleep disorders, for the first time in the year 2006 and a revised version in the year 2017. The current version of the CPG is an update of the earlier versions which specifically focuses on management of sleep disorders in the elderly. The current version of the CPG for sleep disorders in elderly must be read in conjunction with the previous versions of CPG for sleep disorders in the adult population. These guidelines provide a broad framework for assessment and management of sleep problems in elderly patients. Most of the recommendations made as part of the guidelines are evidence-based. However, these guidelines should not be considered as a substitute for professional knowledge and clinical judgment. The recommendations made as part of these guidelines are best available options that have to be modified as per the clinical needs of the individual patient and the treatment setting. SLEEP DISORDERS IN ELDERLY Insomnia and daytime sleepiness are the common sleep complaints in older individuals (table 2). Among the elderly, the prevalence of initial insomnia are found in 15%–45%, middle insomnia in 20%–65%, late insomnia in 15%–54%, and 10% have poor sleep quality. Those having sleep complaints report poor quality of life and higher rates of depression and anxiety. Cognitive deficits can appear because of chronic sleep problems in the elderly that include attentional impairment, difficulties in short-term memory, increase inresponse time and decreased performance. Furthermore, sleep problems increase mortality in older individuals; lower sleep efficiency (<80%) almost doubles the risk of all-cause mortality. The common primary sleep disorders thatare seen in older adults include chronic insomnia disorder (CID), sleep-disordered breathing (SDB), restless legs syndrome(RLS)/periodic limb movements in sleep (PLMS), REM sleep behavior disorder (RBD) and advanced sleep-wake phase disorder (ASWPD).Table 2: Common sleep complaints in the elderlyCHRONIC INSOMNIA DISORDER Insomnia is commonly defined as recurring problems in sleep initiation (sleep onset insomnia) or maintaining asleep (sleep maintenance insomnia). The former is also called initial insomnia, and the later can be either middle or terminal insomnia. Without distinguishing between primary and secondary, ICSD-3 identifies insomnia disorder, that can be divided on the basis of its duration into transient or short-term (lasting only a few days to three to four weeks) or chronic (persisting for more thanthree months). Clinically (as well as using polysomnographic criteria) insomnia is defined as a sleep latency of more than 30 minutes, remaining awake after sleep onset formore than 30 minutes, sleep efficiency of less than 85%, or less than 6 to 6.5 hours total time asleep, occurring on three nights per week or more. Complaints of only non-restorative sleep are no longer sufficient to diagnose insomnia disorder. The diagnostic criteria for chronic insomnia disorder are in table 3.Table 3: Diagnostic criteria for chronic insomnia disorderInsomnia is the most common sleep complaint in the elderly. Insomnia is seen in 20 to 40% of older adults as compared with 9% to 15% in the general adult population. Sleep maintenance insomnia is more common in elderly than sleep onset insomnia. Insomnia disorder leads to fatigue, mood changes, poor cognition, daytime sleepiness and impairment in functioning. Other consequences of untreated insomnia disorder include increased chances of developing mental illness, accidents, poorer quality of life, and greater healthcare utilization. Assessment and Evaluation In the diagnostic evaluation of patients presenting with insomnia, detailed sleep, medical and psychiatric history is essential. Detailed information has to be obtained regarding the initiation of symptoms, its course, and progression. Also, information from the bedpartner is invaluable in arriving at the correct diagnosis. There are several conditions that can be mistaken for insomnia and need to be ruled out before making a diagnosis of insomnia (table 4). Insomnia is associated with several psychiatric disorders (table 5) and medical disorders (table 6) in the elderly. It is pertinent to ask about the prescription as well as non-prescription medications that a person is taking several classes of medications are associated with insomnia (table 7). Sleep log or diary is a primary subjective method which gives nightly information on perceived sleep patterns and quality. It not only aids in the assessment of insomnia but also in monitoring treatment outcomes. Simple forms of sleep diaries may only include information on how much time a person spends in bed, approximate durations of sleeping and waking time, and estimation of sleep efficiency. While starting therapy, sleep diaries are typically filled two weeks prior and continued during treatment and follow up period. An algorithm for the diagnosis of insomnia disorder is presented in figure 1.Table 4: Conditions are mistaken for insomniaTable 5: Insomnia in psychiatric disordersTable 6: Medical conditions associated with insomnia in elderlyTable 7: Medications associated with insomniaFigure 1: Algorithm for diagnosis of insomnia disorderThere are specific scales and other rating instruments available for assessment of sleep and insomnia symptoms (table 8). These instruments aid in the evaluation of patients with insomnia and may be used in addition to history and examination. Objective methods such as polysomnography (PSG) and actigraphy are used in special laboratories for measuring sleep initiation and maintenance variables. PSG is not indicated routinely in the evaluation of insomnia but may be used to rule out other sleep disorders or in non-responders (i.e. when patients do not respond to the first-line medications). Actigraphy is a small device that is worn as a wristwatch that records movement frequency and is a reliable and valid tool for assessing sleep duration.Table 8: Objective assessment scales in insomniaNon-pharmacological management The initial treatment for insomnia in the elderly should include non-pharmacological approaches. Several treatment options for the older individuals are available (see Table 9).Table 9: Non-pharmacological treatment for chronic insomnia disorderSleep hygiene education can be used which includes certain lifestyle changes such as diet control, regular exercise and reducing stimulant and alcohol use, in addition to controlling environmental factors such as ambient noise, light, and temperature that may disturb sleep. Also, it is advised to avoid frequent daytime napping, late evening exercises, and late heavy dinner. A regular exercise regimen and adequate light exposure during daytime have been found useful forinsomnia in elderly. Stimulus Control Therapy: The theory behind stimulus control treatment is maladaptive conditioning between the bedroom environment and bedtime with behaviors that are incompatible with sleep. These behaviors include worrying, reading, using a smartphone or watching TV while in bed. Stimulus control aims at reducing the association between these maladaptive behaviors which maintain arousal during bedtime and increasing the association between sleep and sleep-promoting stimuli. This is achieved by restricting the time one is awake in bed by reducing the sleep-interfering activities, and by maintaining a regular sleep-wake schedule. Instructions to patients for stimulus control include:1) Lie on the bed only when feeling sleepy, 2) Avoid any activity that keeps you awake in the bedroom, other than sex, 3) Sleep only on bed in the bedroom, and not on other places such as sofa, 4) To leave the bedroom soon after waking, 5) To come to bedroom only when feel sleepy, 6) Keep the waking up time fixed, irrespective of the hours of sleep during night, and 7) Avoid napping during day. Sleep Restriction: It includes reducing the duration spent in bed to the actual time asleep, thus creating sleep deprivation and subsequent increase in sleep drive. Before starting sleep restriction therapy, a sleep log for 2 weeks is which gives an of sleep time actual time in bed, i.e. sleep efficiency The sleep time is the subjective sleep time but is less than than time in bed is adequate sleep duration is and can be to sleep and may sleep onset insomnia. used to is used for the treatment of sleep onset insomnia. 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A Sleep can be used to for and other sleep patients with history should be for which can The diagnosis of is summarized in table Detailed in patients with is summarized in table of disorders having is presented in table diagnosis of in elderlyTable history and of disorders that as history ma

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