Sleep in the Elderly: A Common and Growing Problem

Steven H. Feinsilver, MD, EditorView Large Image Figure ViewerDownload Hi-res image Download (PPT)The elderly are the fastest growing segment of the world’s population. Sleep complaints increase with aging, but it is often difficult to distinguish the effects of aging from the effects of diseases and lifestyle changes in this population. It remains unclear exactly what the expected changes in quality and quantity of sleep are in the elderly. We have tried in this issue to review some important principles of sleep medicine for the physician caring for the elderly, emphasizing, where known, how diagnosis and treatment of common sleep problems might be different with aging. The first article reviews what is known about sleep with aging and the epidemiology of sleep diseases in this population. It is difficult to know what sleep changes should be expected in the healthy elderly, but it should not be assumed that sleep necessarily deteriorates; most sleep complaints should be evaluated and addressed in this age group about the same as in a younger population. Insomnia is a particular challenge with aging. The treatment of insomnia should always begin with a behavioral approach, outlined in the article by Ebben. However, behavioral therapy alone is not always practical or sufficient, and the pharmacology of insomnia treatment is discussed in the article by Lou and Oks. Obstructive sleep apnea remains the most significant disease in sleep medicine. Feinsilver reviews a practical approach to positive airway pressure (PAP) treatment. Although PAP is generally very successful, it is not always tolerated, and compliance with treatment can be difficult. Suurna and Krieger review non-PAP approaches to treating this disease. Many patients with obstructive sleep apnea will have relatively mild symptoms of daytime sleepiness, snoring, or disturbed sleep. It is often difficult to know which patients require treatment. Much of this decision making is based on what we know about the consequences of the disease, particularly its effects on the heart and on the brain, as reviewed in the articles by Diamond and Ismail and Chong and Patel, respectively. Ishikawa and Oks discuss central sleep apnea. Although much rarer than obstructive sleep apnea, it remains a significant clinical challenge, and treatment is currently the subject of controversy since the discovery that a previously recommended treatment may have actually increased mortality. Finally, the most significant parasomnia in the elderly, REM sleep behavior disorder, is not rare, may be dangerous, and can be easily recognized by history. This is a very treatable disorder, which may be the earliest manifestation of progressive neurologic disease. This and other parasomnias are discussed by Korotun and colleagues. This has been a remarkably challenging year for this or any project. Many of us have been nearly overwhelmed by the COVID-19 pandemic both professionally and personally. Several of the authors are pulmonary and/or critical care physicians who have had to put sleep medicine on hold for much of the past year. We would like to thank all of our contributors for taking the time to produce this issue, and the editorial staff at Elsevier for their patient support.