Group to Issue Guidelines for Sleep Disorders

Abstract

Sherry Boschert is with the San Francisco bureau of Elsevier Global Medical News. SAN FRANCISCO — Sleep should be viewed as a vital sign, and primary care physicians should address sleep disturbances in all visits with older adults, Dr. Harrison G. Bloom said at the annual meeting of the Gerontological Society of America. “Although there has been more than a decade of discussion about the prevalence and low detection rates of sleep problems, little has changed in primary care practice in recognition of sleep problems in the elderly,” said Dr. Bloom of the International Longevity Center, New York. A first draft of new guidelines for the assessment and treatment of sleep disorders in older people should be ready for discussion within the next few months, produced by his organization in collaboration with other groups, he said. AMDA also recently developed a Clinical Practice Guideline for Sleep Disorders in the LTC setting. “Sleep disorders are prevalent in older individuals and have important consequences, yet very seldom are looked at. It should be a vital sign,” Dr. Phyllis C. Zee said in a separate presentation at the same session. She and her associates interviewed older adults aged 65-102 years in 11 primary care offices in the Chicago area and compared the findings with patient charts. Although 70% complained of some sort of sleep disturbance, only 11% of charts mentioned sleep disturbance, even for patients who reported five or more sleep problems (such as insomnia, difficulty falling asleep, early awakening, or restless legs syndrome). “Sleep problems are so common with aging, yet they're not on the radar screen of most primary care physicians,” said Dr. Zee, professor of neurology and director of the sleep disorders center at Northwestern University, Chicago. Symptoms of some treatable sleep disorders, particularly sleep apnea or rapid eye movement (REM) sleep behavior disorder, may be mistaken for cognitive decline or dementia in the elderly, she said. Multiple factors contribute to the high prevalence of insomnia in the elderly, including medication use, comorbid medical or psychiatric conditions, and psychosocial factors such as bereavement. An assessment of the quantity and quality of sleep should be integrated into the routine review of systems in all examinations of older adults, Dr. Zee said. A growing database of studies directly associates sleep disorders with problems of attention and memory, depression, falls, and metabolic dysfunction, Dr. Andrew A. Monjan said in the same session. Counter to common misconceptions, sleep disturbances are not a natural part of aging but are associated with comorbidities, according to an analysis of epidemiologic data on over 10,000 adults, said Dr. Monjan of the National Institute on Aging. A 2003 telephone poll of 1,500 older people (aged 55-84 years) randomly selected by the institute and the National Sleep Foundation also dispelled the notion that older people need less sleep. People who had four or more medical problems were more likely to report getting less than 6 hours of sleep or having insomnia or excessive daytime sleepiness. Few said they had been diagnosed with insomnia, and even fewer had been treated for insomnia. Pain, obesity, and lack of exercise also contribute to sleep problems. The problem in nursing homes is “even more magnified” due to the frequency of depression, dementia, stroke and other comorbidities, said Dr. Charles Cefalu, CMD, and chair of AMDA's Clinical Practice Committee. Complicating the evaluation and management of sleep problems in the nursing home in particular involves the risk/benefit and cost of formal sleep evaluation, he said. This is especially true as it relates to ruling out obstructive or central sleep disorders in a population of frail elders. For example, the issue of transportation out of the facility for a resident who is bedridden may be problematic. Then there is the issue of an available sleep laboratory, especially in rural settings. LTC physicians also find it difficult to provide adequate non-pharmacological sleep hygiene for residents with insomnia as a first step in management since the nursing home can be a noisy and disruptive environment, especially during twilight hours. Still, Dr. Cefalu said, LTC physicians should consider sleep a vital sign as evidenced-based medicine indicates untreated insomnia results in increased morbidity, mortality, and decreased quality of life.