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Essentials of Diagnosis

  • Patients with insomnia may have complaints of poor sleep quality, daytime fatigue, irritability, or problems with concentration.

  • Nighttime symptoms of sleep apnea may include snoring, choking, and altered breathing.

  • Some sleep disorders are common with neurologic disorders, such as dementia and Parkinson disease.

  • Depending on the particular sleep disorder, diagnoses are made clinically or using polysomnography.

General Principles in Older Adults

The Institute of Medicine’s report, “Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem,” highlighted the prevalence and associated deleterious health consequences of these issues. Sleep difficulties and several primary sleep disorders increase in prevalence with age. However, in older adults, insomnia is most often associated with other conditions, rather than presenting as a primary insomnia. This “comorbid insomnia” often coexists with and can exacerbate or lead to additional medical and psychosocial conditions. For this reason, sleep disorders in older adults should often be approached as a geriatric syndrome as the causes are generally multifactorial.

The prevalence of sleep difficulties varies based on how these problems are identified and defined, but studies suggest that more than 50% of community-dwelling older persons and >65% of long-term care facility residents experience sleeping difficulties. Many community-dwelling older persons use nonprescription or prescribed sleeping medications.

Sleep architecture can be described based on findings of polysomnography, which involves multiple channels (eg, electroencephalogram, electrooculogram, electromyogram) of physiologic recording during sleep. Based on polysomnography, sleep can be categorized into 2 states: nonrapid eye movement (NREM) and rapid eye movement (REM) sleep. NREM sleep is further divided into 3 stages, where N1 is the lightest sleep, N2 is where the majority of sleep time is spent, and N3 is deep sleep. N1 and N2 sleep increase with age, whereas N3 sleep decreases. Altered sleep patterns include decreased sleep efficiency (time asleep as percentage of time in bed), decreased total sleep time, increased sleep latency (time to fall asleep), more arousals during the night, more daytime napping, and other changes.

Patients may not report sleep complaints unless specifically asked. Presenting symptoms overlap significantly among common sleep disorders (Figure 50–1).

Figure 50–1.

Evidence-based recommendations for the assessment and management of sleep disorders in older persons. (Reproduced with permission from Bloom HG, Ahmed I, Alessi CA, et al. Evidence-based recommendations for the assessment of sleep disorders in older persons. J Am Geriatr Soc. 2009;57(5):761-789.)


Clinical Findings

Symptoms & Signs

Occasional difficulty falling asleep or staying asleep is common. To diagnose insomnia, the International Classification of Sleep Disorders—2nd edition (ICSD2), requires that the individual must have a sleep complaint (ie, difficulty initiating sleep, difficulty maintaining sleep, waking up too early, or sleep that is nonrestorative or of ...

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