Review Question - QID 217077

This patient with more frequent nighttime awakenings, increased sleep latency, and decreased sleep quantity without excessive daytime sleepiness or inability to stay up for evening activities most likely has normal age-related sleeping changes.

Sleep changes are common in the elderly independent of other factors such as medical comorbidities and medications. Specific changes include increased sleep latency, increased awakenings during the night, shortened nocturnal sleep duration, and advanced sleep timing. On polysomnography, there is decreased time in slow-wave (phase 3) sleep and decreased rapid eye movement (REM) sleep in older adults. Age-related sleep changes are best managed with reassurance and counseling to improve sleep hygiene. This includes establishing a regular sleeping schedule, avoiding daytime naps, avoiding caffeine or exercise late in the day, maintaining a cool, dark environment for sleeping, and only sleeping in bed.

Li et al. review age-related changes in sleep, changes in sleep architecture with age, age-related changes in circadian rhythm, hormonal changes affecting sleep in older adults, and risk factors for sleep disturbances in older adults.

Incorrect Answers:
Answer 1: Advanced sleep phase syndrome (ASPD) is a disorder in which the timing of sleep is several hours earlier relative to societal conventions. Patients with ASPD sleep well in terms of duration and quality, but have difficulty staying awake in the evenings and wake up very early. Although ASPD is prevalent in older adults, this patient is able to do his normal activities in the evening making ASPD less likely than age-related sleeping changes.

Answer 3: Depression is often accompanied by sleeping problems including difficulty falling asleep, staying asleep at night, excessive daytime sleepiness, or hypersomnia. In patients with comorbid depression and sleep problems, antidepressants such as trazodone can be helpful. However, this patient does not have signs or symptoms of depression, making this less likely.

Answer 4: Insomnia is defined by difficulty initiating or maintaining sleep at least 3 times per week for 3 months. Symptoms of insomnia include daytime fatigue and general sleep complaints. In this patient without excessive daytime sleepiness, insomnia is less likely than normal age-related sleeping changes. Further investigations to consider for insomnia include assessing for urinary complaints, polysomnography, and thyroid function tests.

Answer 5: In obstructive sleep apnea (OSA), the upper airway collapses during sleep causing temporary cessation of breathing and poor sleep quality. Signs and symptoms of OSA include snoring, daytime sleepiness, and nighttime awakenings. However, in this patient that does not snore at night, has normal a BMI, is normotensive, and does not have morning headaches, OSA is less likely.

Bullet Summary:
Age-related sleeping changes include increased frequency of awakenings at night, decreased time in stage 3 sleep, shorter rapid eye movement phase of sleep, waking up earlier, and increased sleep latency.