The notion that aging is a multifactorial process is commonly accepted. Many of the age-related changes that occur in a senior’s nervous system have an impact on the function of sleep. In the elderly, sleeping difficulties often occur in conjunction with depression. Because depression raises the risk of suicide in this population, it is important for pharmacists to question their elderly patients about sleeping difficulties.
Sleep Difficulties Increase With Aging
Complaints of sleep difficulty increase with age, tend to be more common in women than in men, and occur in about 50% of community-dwelling elderly people. The loss of sleep associated with sleep disturbances directly affects quality of life and often contributes to increased risk of chronic fatigue, falls, and accidents. Insomnia, a complaint of poor quality of sleep, results in a sense of nonrestorative sleep. Through both objective and subjective reporting, it has been shown that elderly adults, as compared to younger adults, have longer sleep latency (time to fall asleep), lower sleep efficiency (amount of sleep given the length of time in bed), a higher number of nighttime awakenings, awaken earlier in the morning than they would like, and need more daytime naps. In fact, the sleep pattern is altered in elderly individuals, with a significant decrease in delta sleep, REM sleep, and total sleep time.
Because of frequent nocturnal awakenings involving wandering and confusion, sleep in institutionalized elderly people living in nursing homes is extremely disturbed. The fragmented sleep seen in these elderly people may be such that in a 24-hour period, not a single hour may be spent fully awake or fully asleep.
Providing both emotional and physical restoration, sleep is essential to life. There is a wide interindividual variability in the amount of sleep required per night, ranging from three to 10 hours.
Insomnia and Depression
It is well documented that insomnia is frequently comorbid with various psychiatric disorders, and researchers have indicated that sleep disturbances may be an early sign or the cause of some psychiatric disorders. While chronic insomnia may trigger depression, the converse has also been shown; that is, depression is a common, prominent cause of insomnia. Depressive and anxiety disorders are among some of the most common causes for sleep disturbances in an elderly individual. The actual relationship between insomnia and depression has been studied in older adults. One British study looked at whether sleep disturbances predict depression in seniors 65 and older. Livingston et al reported that a current sleep disturbance was the strongest predictor of future depression in nondepressed older adults. In another study, Roberts and colleagues looked prospectively at Californians 50 and older and found a variety of factors associated with developing depression one year later: sleep problems, psychomotor agitation, mood disturbance, low self-esteem, and loss of feeling and pleasure. Even though the etiology of sleep disturbances in the development of depression is unclear and sleep problems in older adults may not always be related to depression or result in a future depressive episode, it is important to emphasize that further assessment should be done to rule out all medical, psychiatric, or iatrogenic causes of insomnia. Health care professions should suspect that insomnia lasting more than three weeks may be a symptom of a medical or psychiatric disorder.
While reviewing epidemiologic studies, Ford and Cooper-Patrick found that people in the general population may find it easier and less stigmatizing to report symptoms of insomnia more accurately than symptoms of depression such as poor concentration, fatigue, and depressed mood. Additionally, Ohayon and colleagues reported that a large proportion of individuals with concomitant insomnia and depressive symptoms may seek treatment only for insomnia.