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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #66


Learning Objectives

  • Recognize sleep disorders that are most common or particularly important in the care of older adults.

  • Identify key differences in the presentation and recognition of common sleep disorders in older compared to younger adults.

  • Describe evidence-based treatment for sleep disorders in older adults, including insomnia, obstructive sleep apnea, and other common conditions.

  • Summarize important issues in the management of sleep disturbance in special populations of older adults, such as those with dementia and those living in institutional settings.

Key Clinical Points

  1. Poor sleep is common in older adults, and is more closely associated with comorbidities than with chronological age.

  2. Many important health outcomes are associated with poor sleep in older adults, including cognitive decline, increased medication use, and higher health care utilization.

  3. Insomnia is common in older adults, and many of the pharmacologic therapies are relatively contraindicated in this population. Cognitive behavioral therapy for insomnia has a strong evidence base for safe and effective treatment of insomnia in older adults.

  4. In older adults, obstructive sleep apnea (OSA) is less likely to present with classic signs and symptoms, and has been linked with important health outcomes including hypertension, cardiovascular disease, diabetes, and cognitive impairment. Continuous positive airway pressure (CPAP) for the treatment of OSA can be successful in older adults, including those with mild to moderate dementia.

  5. Rapid eye movement (REM) behavior disorder (RBD), which is characterized by dream enactment and lack of normal muscle atonia during REM sleep, can be comorbid with and even the precursor to neurodegenerative disorders such as Parkinson disease, multiple system atrophy, and Lewy body dementia.

  6. Sleep-wake cycle disruption is common in nursing home patients and may be improved by behavioral interventions such as exposure to bright light and maintenance of a regular day-night cycle.


Problems with sleep are frequently encountered in older adults. More than two-thirds of older people with multiple comorbidities report sleep problems. These problems commonly include difficulty falling asleep, difficulty staying asleep, or sleepiness during the day. This chapter will explore the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of sleep disorders commonly encountered in older adults.


Sleep is a reversible behavioral state that is characterized by a decreased responsiveness to the environment and stereotypical changes in the electroencephalogram (EEG). Each sleep period involves a progression of sleep stages on a cycle that averages 90 minutes. There are two major sleep states: rapid eye movement (REM) and nonrapid eye movement (NREM) sleep. REM sleep is characterized by having brain activity that is more similar to wake, REMs, and a complete loss of skeletal muscle tone. When people are awaken from REM sleep they usually report vivid dreaming. NREM sleep is divided into three stages; N1, N2, and N3 (slow wave sleep). As sleep progresses ...

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