54 and Sleep Disorders (1997)

resilience, and engagement in life well into old age. The preservation of excellent-quality sleep into later life not only tells us how someone is actually doing but is also important with respect to continued successful adapta­ tion along both physical and psychosocial dimensions. 4•5 Second, sleep disorders are common in older adults (who take approximately 40% of prescribed sedative hypnotics in the United States) and, if recognized and diagnosed by chief complaints of or excessive sleepiness at inappropriate times of day, can usually be successfully treated or at least mitigated with respect to their adverse impact on the patient's quality of life and on caregiver strain and burden. (The latter consideration is particu­ larly important in the case of the frail elder on the cusp of long-term care placement, since sleep disturbance in the caregiver related to the patient's disruptive nocturnal behaviors may lead to institutionalization.) Even among patients in long-term care placement, including those with progressive neurodegenerative disorders such as dementia of the Alzheimer type, sleep and circadian rhythm disorders are frequently amenable to effective intervention. Finally, the risk of not recognizing and ap­ propriately treating sleep disorders in later life needs to be understood. These risks include deterioration in the quality of life, the development of emotional problems such as depression, worsening of cognitive impairment, and complications of sleep disorders such as motor ve­ hicle accidents. Risk for mortality, also, may be adversely affected by too much sleep (i.e., greater than nine hours out of 24), possibly mediated by sleep apnea, or too little sleep (i.e., less than five hours out of 24) in late life, as epidemiologic data have shown.6 Thus, not only does the quality of sleep affect the quality of life, but also sleep can be, literally, a matter of life and death. Within this context, therefore, this chapter discusses the expected changes of sleep that occur in the elderly and addresses the issue of whether it is usual to sleep less or more as one ages. We will also discuss a definition of insomnia in the elderly, together with the key items in the history in the workup of the elderly individual who complains of insomnia. Indications for referral for formal sleep studies will be reviewed. We will discuss practical, nonpharmacologic approaches to the management of chronic in later life, as well as the role of psychoactive medications in the management of acute and chronic insomnia: Is there a benzodiazepine of choice? Does diphenhydramine have a role? What is the place of zolpidem? Common causes of excessive daytime sleepiness in the elderly, including sleep apnea, nar­ colepsy, and periodic limb movement disorder will be reviewed along with their treatment. Parasomnias, which commonly affect the elderly, are also reviewed. We will also consider the contexts of care, e.g., outpatient, home, and long-term care, where appropriate. This latter focus will include a summary of what is known about the changes of sleep that accompany dementing disorders, a discussion of when intervention is needed, and what in­ terventions are likely to be useful. Finally, we will incor­ porate our view of current research directions in this area, including a focus on what is known about the neural basis of sleep and its changes with aging. To enhance the clinical relevance of this chapter, we will conclude with a discussion of office-based screening and present illustra­ tive case studies.