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Sleep problems are common among the elderly due to physiological changes and comorbid psychiatric and medical conditions. Sleep architecture changes with age. However, sleep disturbances among older adults should not be seen barely as a result of ageing. Depression and anxiety are important differential diagnoses for elderly patients complaining of sleep disturbance. Dementia and delirium are also common causes of sleep disturbances among older people. Elderly people often carry several medical comorbidities. These medical conditions can both lead to and be exacerbated by sleep problems. Given the frailty, multimorbidity and vulnerability of some of the elderly, the management of sleep problems requires additional considerations compared with younger adult patients. Behavioural modifications and drugs of choice will be discussed.
Sleep problems are common in the elderly population. A recent meta-analysis study suggested that the prevalence of pooled sleep disturbance was up to 35.9% in older Chinese adults [1]. Another study in Italy suggested that insomnia was observed in 44.2% of subjects aged 65 or above [2]. While causes of sleep disturbance among the elderly are multi-folded, it is clear that female gender, depressed mood and physical illnesses are general risk factors for sleep disturbance in the geriatric population [3]. Other less robust risk factors in this age group identified by different studies include low physical activity level, low economic status, loneliness and perceived stress [3]. Mild cognitive impairment, long-term use of sedative drugs and high inflammatory markers are also possible predicting sleep disturbance factors [3]. While psychical health issues can affect sleep, poor sleep, in turn, can exacerbate mood and medical problems, causing a vicious cycle. For example, Eguchi et al. [4] demonstrated in their study that short sleep duration is an independent predictor of stroke among the elderly with hypertension. It was also suggested that difficulties in initiating sleep and maintaining sleep in people aged 75 or above were associated with an increased risk of falls, which is a particular worry for elderly people [5]. Poor sleep is closely related to cognitive decline and the mental health of elderly people. However, these problems are often unaware by medical professionals or not optimally and timely managed. The following paragraphs aim to present a general picture of sleep problems in senior groups.
Studies have shown that amount of sleep and sleep architecture change with age. On the one hand, total sleep time, deep slow-wave sleep and sleep efficiency (the ratio of total sleep time to time in bed) decrease with age [6]. A more recent study done by Schwarz et al. [7] on elderly women further suggests that ageing was associated with lower fast spindle and K-complex density in N2. On the other hand, the duration of light sleep increases with age, with elderly people being more easily awakened by external stimuli and resulting in sleep fragmentation [8, 9]. In a study done by Ohayon and Vecchierini [10], the median night-time sleep duration of elderly people aged 60 or above was about 7 hours, with no significant difference found among different sub-age groups of these elderly people. The authors suggested that a short total sleep time was associated with obesity, poor health and cognitive impairment [10]. Therefore, short sleep time and insomnia among the elderly population should not be attributed to ageing alone [10, 11, 12].
Advanced sleep phase syndrome is another key feature of elderly sleep patterns [9, 13]. Elderly people tend to go to sleep and wake up earlier compared with young adults. Biologically, this can be a result of the decrease in the suprachiasmatic nucleus(SCN) volume and cell count and a decrease in melatonin secretion [13, 14]. Various other physiological malfunction processes at the cellular and systematic levels also contribute to circadian desynchrony and alternation of sleep patterns among elder people [13]. Psychosocially, advanced sleep phase syndrome can also result from lifestyle changes after retirement and subsequently reduced light exposure [8, 13]. With a generally more sedentary and less social lifestyle, there is little drive for older adults with advanced sleep phase syndrome to reschedule their bedtime [8].
Insomnia is the predominant sleep problem found among the elderly population. While there are no well-recognised diagnostic criteria or classification systems dedicated to insomnia disorder in the senior age group, a general framework for insomnia can be used in the encounter with elderly patients. According to DSM-5, insomnia disorder refers to dissatisfaction with the quality and quantity of sleep that cause distress or impairment in daily function [15]. To fulfil the diagnostic criteria of insomnia disorder, one has to experience sleep difficulty despite sufficient chances to sleep, and the sleep difficulty should last for at least three days a week [15]. Sleep difficulty could arise from difficulties in falling asleep (sleep initiation), frequent awakening and difficulty in returning to sleep (sleep maintenance) or early-morning awakening (late insomnia) [15]. Sleep fragmentation is common in the elderly population, especially those with dementia. Demented patients, as mentioned below, are also subject to early morning awakening.
Insomnia disorder can be classified according to its chronicity and aetiology. According to the International Classification of Sleep Disorders (ICSD)-Third Edition, insomnia is considered chronic for over three months [16]. ICSD classifies the aetiology of insomnia into primary and comorbid [16]. Similarly, DSM-5 includes specifiers of insomnia according to the comorbid conditions, i.e. with non-sleep disorder mental comorbidity, with other medical comorbidity and other sleep disorders [15]. Elderly patients are subject to multiple comorbidities and polypharmacy. Insomnia is a common result of these chronic conditions. Therefore, the diagnosis of chronic insomnia is better reserved for patients for whom insomnia is especially prominent, unexpectedly prolonged and is one of the foci of treatment plans [16]. Pharmacological treatments for chronic insomnia in the elderly should be prescribed with caution in view of the possible serious side effects of certain drugs among elderly patients (see below).
As with other psychiatric conditions, the causation of insomnia can be understood in terms of biological mechanisms and psychosocial aspects. The two-process model of sleep–wake regulation depicts the roles of melatonin and adenosine, which regulate circadian rhythm regulation and sleep–wake homeostasis, respectively [17]. Dysregulation of the circadian rhythm can lead to difficulty in sleep initiation and early morning awakening, while dysregulation of sleep–wake homeostasis may lead to sleep initiation and maintenance difficulties [17]. Cajochen et al. [18] suggested that age-related changes in sleep structure are mainly due to a reduction of circadian force. At a neural circuitry level, the reticular activating system that comprises cholinergic, monoaminergic, histaminergic and glutamatergic neurons is responsible for wakefulness, in contrast to the GABAergic neurons that promote sleep [17]. Pathology in the relevant neural substrates may explain insomnia in patients with Parkinson’s disease and possibly Alzheimer’s disease [19]. Some scholars suggest that monoamines could be the link between REM sleep and depression [20]. However, as with the case of dementia, the exact neural mechanisms between insomnia and mood disorders are yet to be clarified.
In terms of psychosocial aspect, the 3 P models, i.e. predisposing, precipitating, and perpetuating factors, can be used to understand the course of insomnia in elderly people.
3.1.1 Predisposing factors
As mentioned above, some demographic factors are reported to be related to an increased risk of sleep disturbances. Many of these factors are also predisposing factors for insomnia, including female gender and lower socioeconomic status, and physical and mental health illness [21]. Divorced couples and widowers also have a high prevalence of insomnia [21]. This agrees with the findings mentioned above that loneliness is associated with sleep disturbance [3]. Family history of insomnia, poor sleep hygiene, stress, poor sleep environment, low physical activity level and use of substances are other predisposing factors that clinicians should consider [21, 22, 23]. Loss of a spouse and low physical activities are also relevant concerns for elderly people.
3.1.2 Precipitating factors
New onset or deterioration of medical and mental illnesses can precipitate insomnia in the elderly. Symptoms and worrisome brought by medical diseases can affect sleep quality. Hospitalisation, and certain drug use, such as decongestants and steroids, also precipitate insomnia [23, 24]. Psychological stressors and stressful life events that precipitate insomnia include financial problems, changes in living environment, e.g. moving to nursing homes, and the death of loved ones [24, 25].
3.1.3 Perpetuating factors
Perpetuating factors are behavioural and cognitive changes that occur after the onset of diseases and prolong an acute insomnia episode into chronic problems [23]. Patients with insomnia may take frequent naps that compensate for short or poor night’s sleep. Besides, they may stay awake for a prolonged time in bed due to difficulties falling asleep [23]. These maladaptive behaviour changes can prolong and worsen the problem of insomnia. From the cognitive aspect, patients may be worried or even anxious about not being able to fall asleep, which further worsens insomnia [23]. A vicious circle is formed, and patients may eventually rely heavily on medications to treat insomnia.
3.2 Sleep, depression and anxiety
Sleep disturbances, mainly insomnia, are common symptoms of depressive disorders and general anxiety disorder. A recent longitudinal study on middle-aged and older people suggested a bidirectional relationship between short sleep duration and depression [25]. Several other studies also indicated that perceived poor sleep quality correlates with depressive and anxiety symptoms among elderly people [26, 27, 28]. Therefore, depression and anxiety are important differential diagnoses for elderly patients who present with sleep disturbance.
3.2.1 Late-life depression
The presentation of depression in elderly people may be different from that among younger adults. Elderly people may be less likely to complain of low mood than younger adults. In contrast, they may show more irritability, anxiety and somatic symptoms [29]. Also, non-demented elderly patients with depression may present like cognitive impairments [30]. Indeed, a close relationship between depression and cognitive functions in elderly people has been reported. Depression is found to be associated with the occurrence and progression of neurocognitive disorder [31, 32]. Physical health-related risk factors of depression among older adults include chronic diseases, especially vascular-related diseases, disability and self-perceived health [33]. Several mechanisms have been proposed to explain the biological basis of late-life depression. The vascular depression hypothesis suggests that cerebrovascular diseases or cerebrovascular risk factors can lead to depression [34]. The hypothesis is supported by imaging studies and the fact that depression is more common in post-stroke patients [29, 34]. The inflammation hypothesis suggests that the persistent activation of microglia and inflammatory response within the brain lead to an imbalance in the cytokines system and subsequently lead to neuronal death and reduced neuroplasticity [34]. Psychological risk factors of depression among elderly people include maladaptive coping strategies and negative self-image [33].
3.2.2 Generalised anxiety disorder
A recent study done in a multicentre setting suggested that the prevalence of generalised anxiety disorders was about 3.1% in the elderly [35]. Although not all studies suggested a strong co-occurrence between generalised anxiety disorder and depression in the elderly population, there is a high overlap in the symptoms between the two disorders and co-occurrence in the clinical population [35, 36]. Elderly patients with GAD may also present with frequent somatic complaints with unexplained symptoms [36]. The biological and psychological risk factors of anxiety and depression show significant similarities [33]. It has also been suggested that elderly patients with GAD may progress to depression [36, 37]. Therefore, the clinician should screen for depression in patients the present with symptoms of generalised anxiety disorder, including sleep disturbances. Deteriorated physical health and life events can lead to worrying in elderly people. Clinicians need to identify excess, uncontrollable and unrealistic worrying of elderly people that may suggest anxiety disorders [36].
The decline in cognitive functions is common among the elderly population. Mild cognitive impairment (MCI) refers to a syndrome where one’s experiences cognitive decline more significant than expected with regard to one’s age and education while activities of daily living are not notably interfered with [38]. Dementia, in contrast, refers to a great extent of cognitive decline severe enough to affect daily living [38].
Sleep problems are common in people with MCI and dementia, particularly in patients with Alzheimer’s disease (AD) and Lewy body dementias (LBD) [39]. The elderly with different types of dementia may present with different kinds of sleep disturbance. Sleep disturbance is a predictor of more severe cognitive and neuropsychiatric symptoms and poorer quality of life [39]. However, it does not mean that the longer the sleep duration, the better for the demented patients. Indeed, results from a meta-analysis suggest that too short (i.e. less than 5 hours) and too long sleep duration (i.e. longer than 9 hours) also correlated with the poor cognitive performance of various domains, including executive function, as well as verbal and working memory [40].
4.1 Alzheimer’s disease
Alzheimer’s disease is the most common and well-known cause of dementia worldwide [41]. Pathogenesis of the diseases involved amyloid plaque and neurofibrillary tangle formation that is associated with neuronal loss and cognitive decline in affected patients [42]. Common psychiatric symptoms are apathy, followed by depression, aggression, anxiety and sleep disorder [43]. Of note, about 40% of AD patients experience sleep disorders [43].
Sleep problems of people with AD can present in different ways. One of the common presentations is significant sleep fragmentation, i.e. more frequent and longer period of intra-sleep wakefulness [44]. Although awakening is not the most common sleep disturbance among AD patients, it brings the most disturbance to caregivers [45]. Factors associated with night-time awakening include male gender, more severe memory and functional deficit [45]. Other sleep problems include daytime sleepiness and early morning weakness [44, 45]. Some patients experience a shift in sleep–wake rhythm; in extreme cases, the patients may exhibit day/night sleep pattern reversal [46]. However, in end-stage AD, patients may appear to sleep throughout the day with brief periods of awakening [46].
Sundowning, referring to an increase in behaviour disturbances in demented patients late in the day, is common among patients with AD [46]. Sundowning can begin in the later afternoon or early evening. Sundowning behaviour includes agitation, reduction in attention, disorganised speech, motor disturbance like wandering, hallucinations and emotional disturbances, e.g. anxiety and anger [46]. Sundowning itself reflects a disturbed diurnal rhythm of the affected patients, and improving the nocturnal sleep problem of the patients may alleviate the symptoms of sundowning [46].
Studies have also suggested that altered sleep duration, sleep fragmentation and insomnia are associated with risk of MCI and AD [39]. Although it is not sure whether sleep disturbance is an early marker of cognitive impairment, or causes cognitive impairment, good sleep seems to be a protective factor against AD [39].
4.2 Lewy body dementias
Lewy body dementias refers to dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PD-D) [47]. Hypersomnia is common in patients with Lewis body dementias due to nocturnal sleep fragmentation, sleep apnea, periodic limb movement and change in sleep–wake physiology [47]. For PD-D, other behavioural features associated with PD-D include apathy, loss of motivation, change in personality and psychosis [48]. Visual hallucinations are more common than other sensory modalities of hallucination and are usually complex, e.g. seeing people, objects and animals [48]. Delusions are usually paranoid in nature or phantom border [48].
The clinical features of DLB and PDD are similar. Similar to PD-D, patients with DLB may also experience detailed and well-formed visual hallucinations of people, animals or objects [49]. DLB patients may present with daytime drowsiness and disorganised speech [49]. Fluctuations in cognition, attention and arousal are typical characteristics of DLB [49]. A core features of DLB are REM sleep behaviour disorder (RBD) which may precede cognitive decline [49]. RBD can lead to significant injuries that require hospitalisation, yet its prevalence may have been underestimated [50].
4.3 Sleep-disordered breathing and cognitive impairment
Both obstructive and central sleep apnea prevalence increase with age [51, 52]. The prevalence of sleep-disordered breathing (SDB) is higher in men than women, yet the difference disappears in the elderly age group [52, 53]. Cognitive impairments are also common in patients with sleep-disordered breathing. Studies suggested that obstructive sleep apnea is associated with neurodegeneration and pathological process closely related to Alzheimer’s disease [53]. A study done in a multicentre setting in Italy also showed that around 60% of patients with different degrees and types of neurocognitive impairments had SPD [54]. In fact, elderly people with obstructive sleep apnea are associated with a range of medical conditions in addition to cognitive decline. These medical conditions include cardiovascular diseases, stroke, chronic pulmonary diseases and depression [55]. While the metabolic mechanisms behind it are not well defined, OSA leading to intermittent hypoxemia, followed by sympathetic activation, sleep fragmentation and sleep deprivation, are believed to be part of the reasons. Diagnosis of OSA in elderly patients is easily missed, partly due to the non-specific symptoms. Some of these presentations are common in elderly people without OSA, including nocturia, gait disturbance, and post-operative delirium. Other symptoms may mimic other neurological and psychiatric conditions, including limb movement during sleep, fragmented sleep, mood disturbance and daytime attention.
While daytime sleepiness is one of the key presentations of OSA, studies have shown that daytime sleepiness is less common among elderly patients compared with younger patients [56]. Although continuous positive airway pressure (CPAP) has been proven to be effective in improving symptoms of OSA, its acceptance among elderly patients is reported to be low. Studies in Asia showed that CPAP is not accepted by a majority of elderly patients [57, 58].
Multimorbidity is a characteristic of patients in the older age group. Medical diseases can lead to sleep disturbance in several ways. Symptoms of medical diseases disturb sleep (Table 1). Besides, medical diseases can precipitate mood disorders that further worsen sleep problems. Sleep problems, in turn, can worsen disease outcomes. Examples include stroke [62], diabetes mellites [64] and cardiovascular diseases [65]. The relationships among medical disease, mental illness and insomnia can be complex. One example is chronic pain in elderly people. Chronic pain is common in elderly people. Chronic pain can directly lead to sleep and psychological distress. Studies suggested that chronic pain is strongly associated with depressive and insomniac symptoms among the elderly [66, 67]. On the other hand, patients with depressive symptoms with or without insomnia are more likely to experience distress from pain [67]. A more recent study that looked into the temporal relationship between insomnia and chronic pain suggested that insomnia could be a risk factor for chronic musculoskeletal pain, with depressive symptoms bearing a partial mediating effect [68].
System
Disease
Symptoms/conditions contributing to sleep problems
Common medical diseases and related symptoms or conditions in elderly people that disturb sleep.
Elderly patients may not volunteer sleep problems when seeing doctors for medical diseases. For the sake of holistic care and a better outcome for medical diseases, sleep problems should be considered to ask during consultation for relevant elderly patients, especially in primary care settings.
Delirium refers to an acute deterioration of attention, cognition and consciousness. Delirium is common in elderly people in admission, especially in the ICU setting [69]. While old age is a predisposing factor for delirium, older adults can bear multiple predisposing factors that make them vulnerable to delirium. These predisposing factors include underlying cognitive impairment, sensory deficits, comorbidities and low functional state [70]. Common precipitating factors for delirium include medication, particularly polypharmacy and use of psychoactive drugs, infection, bladder catheter, electrolytes and metabolite disturbance, trauma and surgery [70]. Sleep and delirium are highly related. One of the key supporting features of delirium sleep–wake cycle disturbance, while sleep deprivation can predispose to delirium [69, 70]. Poor sleep environment and circadian misalignment in hospitals therefore can contribute to delirium in elderly people in admission [69]. Drug choice for delirious patients is important. Opioids, sedating and hypnotic drugs, including benzodiazepine and anticholinergic, can precipitate delirium [69, 70]. Although antipsychotic and sedative drugs may reduce agitation and behavioural symptoms of patients, these medications may turn patients with hyperactive delirium into hypoactive delirium [70]. Hypoactive delirium tends to be under-recognised by clinicians and has poor survival outcomes [70, 71]. Therefore, non-pharmacological treatment and reduction of the insulting drugs should always be considered first and maximised in delirious patients [69, 70].
The rest of the chapter focus on the clinical approach and management of older adults with sleep disturbance. The general clinical approach for sleep disorders in elderly is illustrated in Figure 1. Sleep complaints can be related to 1) sleep pattern, 2) quantity, 3) sleep quality and 4) underlying causes for sleep disturbance.
Sleep pattern Sleep: Disturbance can occur at different time points throughout sleep. Starting from the onset of sleep, elderly people may complain of advanced or delayed sleep phase syndrome. Some elderly people may even show a day-night reversal sleep pattern or stay awake for most of the night. Elderly patients may experience sleep latency, i.e. difficulty in falling asleep. In the middle of sleep, patients may experience difficulties in maintaining sleep and easy awakening, i.e. sleep fragmentation. Towards the end of sleep, early morning awakening can signify neurocognitive disorders or mood disorders.
Quantity: Older adults may have short night sleep or total sleep time. On the contrary, some older adults may complain of hypersomnolence or increased time on napping during the daytime.
Quality of sleep and effects on daily living: Some older adults may complain of non-refreshing sleep, resulting in daytime sleepiness or prolonged day sleeping. Sleep problems can relate to reduced concentration, mood disturbance, poor memory, falls and a decrease in daily functions [24].
Underlying causes of sleep disturbance. For patients suffering from insomnia, identify the 3-P (see above.) Signs and symptoms of mood disorders and medical diseases that can lead to sleep disturbance, if any, should also be explored. Patients’ spouses or caregivers can also be asked for any snoring, witness apnea, limb movement or parasomnia of the patients.
Figure 1.
General approach for elderly people with sleep disturbance.
Several screening tools can be considered for symptom evaluations (Table 2).
Correlated with psychological symptoms in middle age and older adults [74]
Screening symptoms of anxiety and depression
Hospital Anxiety and Depression Scale
Possible ceiling effect, but adequate for the general older population [75]
Assessing the severity of depressive syndromes
Hamilton rating scale for depression
Need trained interviewer; for patients with depression disorders [76]
Screening elderly people with depression
Geriatric Depression Scale
Several forms with different lengths available; have high sensitivity and specificity [77]
Screening anxiety symptoms
Geriatric Anxiety Inventory
Validated for elderly people, available in several languages [78]
Identifying cognitive impairments
Montreal Cognitive Assessment (MoCA)
Measure various cognitive domains
Mini-Mental State Examination
Ceiling effect copy right issue Shorter
Identifying delirium
Confusion Assessment Method
Widely used in clinical settings with good sensitivity [70]
Screening for REM sleep behaviour disorder
REM sleep behaviour disorder screening questionnaire
High sensitivity but relatively low specificity [79]
Table 2.
Screening tools for elderly people with sleep problems.
7.2 Non-pharmacological management
7.2.1 Non-pharmacological Management for Insomnia
A wide range of management options for insomnia is listed in Table 3. Several non-pharmacological managements can be considered in elderly patients with insomnia. Cognitive behavioural therapy for insomnia (CBT-I) is recommended as a first-line treatment for chronic insomnia [82]. CBT-I should also be always considered for elderly patients, yet, there are more challenges during implementation and flexibility is required [81]. CBT -I consist of psychoeducation, relaxation therapy, cognitive therapy and behavioural strategies, which include sleep restriction and stimulus control [82]. For sleep education, elderly patients should be advised to construct a daily sleep routine and avoid going to bed too early [81]. As mentioned before, the sleep advancement phase is common in elderly people, partly due to psychosocial reasons. Elderly people be encouraged to set a sleep schedule to prevent going to bed too early. A comfortable and suitable sleep environment is essential. For hospitalised or institutionalised elderly people, sleep disruptions from the sleep environment should be minimised. Night-time lighting, bed restraints, TV noise or interference from other patients are common causes that disturb wards or nursing home sleep environments [81, 85]. For patients staying in nursing homes, caregivers can decorate the sleep environments with objects that elderly people are familiar with [85]. For example, elderly people can bring their own pillows, blankets or other personal belongings with them to nursing homes [85]. Lifestyle changes imported for elderly people include ensuring regular daytime physical activities and avoiding prolonged napping [81, 85]. For stimulus controls, elderly patients should not stay in bed or bedroom in case of difficulties in falling asleep. However, due to pain or immobility, implementing stimulus control can be difficult [81]. Sitting up patients, listening to music, reading and other non-stimulating activities can be carried out instead [81]. Similarly, sleep restriction is effective but difficult to be carried out in institutionalised elderly people or those who are ill [81]. Sleep restriction can aim to reduce the total time spent in bed by 20–30 minutes every week to increase sleep efficiency [81]. Cognitive behaviour therapy can also be used to treat underlying mood disorders related to sleep problems. Cognitive sleep therapy can improve symptoms of anxiety disorders [86, 87], although the reported effectiveness varies and is not superior to medication. CBT may also show a decreased effectiveness in elderly patients with anxiety and cognitive impairment [86].
Treatment modalities
Indications
Content/application
Advantage and disadvantage
CBT
Insomnia and related mood disorders
Sleep hygiene
Maintain activity level
Stimulus control
Sleep restriction
Relaxation therapy
Mindfulness
Cognitive therapy, e.g. avoid secondary worrisome due to insomnia
Bring risks of falls and delirium in elderly people
Beware of misuse
Avoid long-term used
Anti-depressants
Depression, anxiety disorders and related sleep problems
SSRI and SNRI can be used for depression and anxiety disorder
Mirtazapine, trazodone and doxepin carry hypnotic effects
Trazodone may bring serious effects in elderly people, including of orthostatic hypotension, cardiac arrhythmias, priapism and psychomotor and cognitive impairment [23, 24, 83]
Light therapy has been proposed for elderly people with sleep problems. However, the effectiveness of light therapy on elderly people with sleep disturbance was in doubt. While a systematic review done showed light therapy brings little benefit for elderly people with primary insomnia [80], a more recent meta-analysis supported the efficacy of light therapy in treating geriatric nonseasonal depression [88]. Studies also suggested that bright light therapy can compensate for circadian rhythm alternation in demented patients [89]. However, evidence for light therapy for the treatment of elderly sleep disturbance is not strong and should be considered as an adjunct therapy [82].
7.2.2 Considerations for caregivers of patients with cognitive impairments
Frontline healthcare professionals should advise caregivers on handling sleep-related problems in elderly people with MCI or dementia. Elderly people with MCI or dementia may wander around at night, even leaving their living place at midnight. The following advice may be helpful for caregivers of these elderly people, for example, their family members [85]: 1. adopting an accepting attitude. Caregivers should avoid direct conflicts with elderly patients. Direct conflicts may agitate the elderly. Instead, caregivers can start the communication with an open-ended question, e.g. “How can I help you with”, or “What are you looking for?”; 2. Orienting the elderly patient with environmental cues. Caregivers can show the patients a clock or bring them near the windows to orient them to time; 3. Following the elderly patient and confining the time and place of wandering. Sometimes the patients may exhibit a strong wish to leave their living place for their “home”. It may not be easy for caregivers to stop them. In those situations, caregivers will have to follow the elderly patient. The caregivers can try to communicate with the elderly and set an agreed area and duration of wandering.
It is worth mentioning that sleep problems are not only common among elderly patients with dementia, but also among their caregivers. Night-time awakening and short total sleep of patients significantly impair caregivers’ sleep [46]. Taking care of demented patients can mount significant mental stress on caregivers. The stress comes from the heavy workload of taking care of the patients and the patient’s behaviour disturbances [46, 85]. Therefore, caretakers are prone to mental health problems, including insomnia, comorbid anxiety and depression [85]. Caregivers may present with mood disturbance, somatic complaints, feeling of guilt, suicidal ideation or aggressive behaviours towards the patients [85]. Given that demented patients are often seen together with their caregivers in the clinical settings, frontline healthcare workers should beware of the signs and symptoms of mood disorders of the caregivers [85]. Suitable mental health education and referral should be provided to the caregiver when indicated.
7.3 Pharmacological interventions
Although non-pharmacological interventions are preferable because of their minimal, if any, side effects, they do not quickly help patients with sleep problems. Pharmacological interventions have to be considered when sole non-pharmacological interventions do not suffice. Polypharmacy and multiple medical comorbidities are common in older adults and have to be considered when deciding on management plans [24]. Risk-gain balance determines the use of drugs. Fall and cognitive impairments are important considerations for older adults with insomnia treated with drugs. The following provides a brief overview of the general features of common hypnotics on elderly patients. For more details on using of each drug on older people, please view [24].
7.3.1 Z-drugs and benzodiazepine
A meta-analysis that looked into the effect and adverse drug effects of Z-drugs and benzodiazepines suggested that the effects of sedatives may be diminished in elderly people compared with younger adults [90]. The same meta-analysis also concluded that these sedatives were associated with a higher incidence of falls and likeliness of morning or daytime sleepiness among elderly people [90]. These drugs may impair older adults’ balance and cognition and subsequently lead to falls [91]. A higher risk of falls and fractures is related to dose, acting time of agents, concurrent using interacting drugs and time from treatment initiation; that is, 1–2 weeks after treatment initiation is associated with a high risk of falls [91]. Evidence also suggests a higher rate of fracture associated with Zolpidem compared with other benzodiazepines [91].
In elderly patients with severe generalised anxiety disorders and RBD, the use of benzodiazepines is more justifiable [92]. Otherwise, the use of benzodiazepines to treat insomnia should be minimised in elderly people due to the increased sensitivity and decreased metabolism in elderly [92]. Apart from the risk of falls and fractures, benzodiazepine may increase the risk of cognitive decline and delirium [92]. There is also a high risk of misuse of benzodiazepines among elderly patients, who are more vulnerable to the serious effects of benzodiazepine misuse [93]. Benzodiazepine should not be routinely used to treat elderly patients with insomnia [24]. Withdrawal and discontinuation of benzodiazepines should always be considered, given the benefits of doing so on the psychical and psychological health of elderly patients [93].
7.3.2 Melatonin and Ramelteon
Melatonin may be considered a safer alternative to benzodiazepines in some patients as melatonin is believed not to cause withdrawal and dependence symptoms [94]. Ramelteon is a melatonin receptor agonist, which has been shown to be effective for older adults with chronic insomnia in different studies, particularly for those with difficulties in falling asleep [24, 95]. There is also evidence suggesting ramelteon may help prevent delirium in medically ill elderly people [96].
7.3.3 Other drugs for insomnia
Some other drugs are used to treat insomnia. Diphenhydramine also provides a sedative effect; however, the possible strong adverse effects in elderly people, including confusion, constipation, dry mouth and cognitive decline in long-term use, suggested that diphenhydramine should not be used for chronic insomnia [24, 92]. Suvorexant is an orexin receptor antagonist that was approved in the USA and Japan for treating insomnia at doses of 10–20 mg [97]. There is evidence suggesting no association between cognitive, psychomotor performance and drug usage at therapeutic dose [98]. Nevertheless, it is still recommended that patients of this drug should take driving precaution and monitoring of apnea-hypopnea index in case of sleep apnea [24].
7.3.4 Drugs for mood disorders, dementia and delirium with sleep problems
Several antidepressants have been used to treat anxiety disorders and depression in elderly patients. Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are the mainstay of treatment for late-life anxiety disorders, while benzodiazepines are for patients with severe anxiety [86, 92, 99]. Effective SNRIs for treating anxiety disorders in the elderly include venlafaxine, duloxetine, desvenlafaxine, vortioxetine and mirtazapine [99]. Particularly, mirtazapine carries sedating effect and also can increase patients’ appetite [84, 99]. Mirtazapine is thought to be a safe option for elderly patients due to its low cardiotoxicity and no significant changes in vital signs when compared with the placebo group [84]. However, compared with younger adults, older adults on mirtazapine may have a higher chance of experiencing dry mouth, constipation and dizziness [84]. In addition to mirtazapine, trazodone and doxepin are also antidepressants that help insomnia. Use of trazodone in the elderly requires particular cautions due to risks of orthostatic hypotension, cardiac arrhythmias, priapism and psychomotor and cognitive impairment [23, 24, 83]. Doxepin, a tricycle antidepressant, can help elderly people with sleep maintenance [23, 24]. It has few adverse effects on memory and cognitive function [24]; however, reduced clearance of the drug in elderly people with low reduced renal functions may lead to prolonged sedation [24].
Some of the drugs mentioned above are also used in AD patients with insomnia, including low-doze trazodone, mirtazapine and melatonin [39]. Drugs with anticholinergic activities, including antihistamines and tricyclic antidepressants, may exacerbate cholinergic abnormalities and should be avoided in treating elderly patients with AD and insomnia [46, 100]. For patients with LBD, hypersomnia in Lewis body dementia can be treated with modafinil, although some researchers may consider the supporting evidence not strong [47]. Insomnia can be treated with low doses of melatonin [47]. Mirtazapine may exacerbate REM sleep behaviour disorder [47]. lBD patients with autonomic dysfunction may experience orthostatic hypotension, and head elevation during sleep may be needed [47].
Antipsychotics are used in demented elderly patients who are psychotic, severely agitated, aggressive and need drug treatment for sleep [39, 46, 100]. However, the use is controversial due to the possible increase in mortality [39]. For patients with LBD, quetiapine or clozapine is preferred due to their sedative and antipsychotic effects [46]. However, some scholars do not support the use of these antipsychotics in LBD, given little supporting evidence and possible adverse effects on the motor and cognitive of patients. Similarly, use of antipsychotics in patients with hyperactive delirium is also controversial. Some scholars deem the evidence supporting the effectiveness of antipsychotics on delirious elderly people weak [70]. For example, olanzapine may reduce incidence but increase the duration and severity of delirium [70]. Pharmacological treatments in hyperactive delirium for pain relief and sleep enhancement using melatonin are, nevertheless, preferable [70].
Insomnia is common in elderly people. Identifying underlying psychiatric and medical comorbidities is important for management. Non-pharmacological should always be maximised. Pharmacological treatments are effective, but special cautions are needed to protect elderly people from possible but serious adverse effects, including falls and cognitive decline. Antipsychotics are commonly used in clinical practice for agitated elderly people with dementia and delirium. However, adverse effects may not outweigh the benefits, and limited evidence supports the use of antipsychotics in these patients.
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Written By
Pak Wing Cheng and Yiu Pan Wong
Submitted: 29 November 2022Reviewed: 21 April 2023Published: 17 May 2023
Open access peer-reviewed chapter
