Growing Old Should Not Mean Sleeping Poorly: Recognizing and Properly Treating Sleep Disorders in Older Adults

The last decade has been an exciting period for sleep research and sleep medicine, especially in the area of geriatric health care. There have been significant and rapid advances in our ability to diagnose and treat, behaviorally and pharmacologically, sleep disorders generally and in older adults in particular. These important scientific and healthcare advances have been contemporaneous with other major movements in the sleep field, including the continued healthy growth of societies like the Sleep Research Society and the American Academy of Sleep Medicine, nonprofit foundations such as the National Sleep Foundation advocating the importance of sleep for health and safety, and the recent recognition of sleep medicine as a medical subspecialty. Within the context of burgeoning sleep research, medicine, and advocacy, the Institute of Medicine (IOM) of the National Academy of Sciences recently released a report entitled ‘‘Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem.’’ This report recognizes that sleep disorders and sleep deprivation are significant public health problems that have a wide range of deleterious health and safety consequences. The IOM calls for increased awareness among healthcare professionals about the physiology of healthy sleep and sleep disorders across the lifespan and the development and implementation of programs to promote the early diagnosis and treatment of sleep disorders. Fragoso and Gill’s review is a timely exercise of these recommendations in the context of geriatric healthcare practice. Fragoso and Gill provide a masterly, comprehensive overview of the causes of sleep disorders in older adults, emphasizing the multifactorial origin of most sleep disturbances in this population. They detail how age-related changes in homeostatic and circadian sleep regulatory mechanisms, changes in health and functional status, primary sleep disorders, and psychosocial influences can disturb sleep and how several of these factors are often simultaneously at play in an individual patient. They argue that, because of its multifactorial origins, sleep disruption can be conceptualized as a geriatric syndrome. They further incorporate these factors into the classic model of insomnia proposed by Spielman and colleagues, providing a useful heuristic for appreciating the intricacies of the interactions between the various causes of sleep disturbance and health. Finally, they provide a clinical application of these principles and close with the recognition that appropriate treatment of sleep complaints in older adults requires a comprehensive geriatric assessment, sensitivity to the multiple causes of sleep disturbance common to this population, and recognition that effective treatment needs to be comprehensive, iterative, and long term. Fragoso and Gill have gone a long way toward ensuring that older adults, with appropriate diagnosis and treatment of the underlying factors, can obtain the best sleep possible and are not consigned merely to getting the sleep they do, because they are simply ‘‘getting older.’’ That epidemiological studies show that 50% of older adults complain of significant sleep disturbance is a cliché of the sleep and aging literature. The other 50% do not complain, suggesting that aging, per se, clearly does not result in more sleep complaints. The accepted wisdom has been that the age-related sleep changes begin to appear in early adulthood and progress steadily across the adult human lifespan, although a recent meta-analysis of studies by Ohayon et al. using objective sleep measures across the human lifespan demonstrated that, in healthy, carefully screened, noncomplaining adults, the bulk of the changes seen in adult sleep patterns occur between early adulthood and age 60, declining only minimally from age 60 to age 102. This and other studies clearly indicate that aging in the later human life-span, per se, has a relatively small effect on sleep quality. Rather, as Fragoso and Gill point out, factors that form the fabric of usual, as opposed to healthy, aging such as ‘‘reduction in health status, loss of physical function, and primary sleep disorders . . . are capable of precipitating sleep complaints and adverse outcomes.’’ That is, the factors that impair sleep in older adults are diagnosable and treatable. Much progress has been made in understanding sleep disturbances in older adults; advances include improvements in the behavioral and pharmacological management of insomnia and better recognition and treatment of sleep apnea and restless legs syndrome, but the journey is far from complete. Better, more-specific behavioral and pharmacological interventions need to be developed. More attention needs to be paid to the sleep of older adults with degenerative neurological disorders and their caregivers, whose sleep is often greatly compromised as well, more attention needs to be paid to improving the sleep of institutionalized older adults, and finally, primary care physicians need not only to take the sleep complaints of their older patients seriously, but also need to query their patients, regardless of age, about their sleep. DOI: 10.1111/j.1532-5415.2007.01401.x