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��ࡱ�>��	#&���� !"������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	���abjbjOO	.�-a-a�Y�������NN��������������Xd��,f��������A,C,C,C,C,C,C,$V.�1vg,������g,�����|,8�"�"�"�����A,�"�A,�"�":'',�'�����0�x��������� S'
-,�,<�,]'R~1�!~1�'�'f~1�)���"�����g,g,�"����,������������������������������������������������������������������������~1���������N n:	Title: Sleeping Through the Ages: An Examination of Sleep in Older Adults

Authors:  Pennie S. Seibert, Ph.D.,1,2 Jennifer Valerio, B.S.,1,2 CodieAnn DeHaas, B.S.,1,2 and Fred Grimsley, RSPGT, CRT 1

Author Affiliations: 1Physician Research Services at Saint Alphonsus Regional Medical Center, Boise, Idaho; and 2Boise State University, Boise, Idaho
Corresponding Author:
Pennie S. Seibert, PhD
1055 North Curtis Road
Boise, ID 83706
E-mail:  HYPERLINK "mailto:penseibert@msn.com" penseibert@msn.com
Fax: 208-367-6821

Abstract:
It is widely recognized that sleep disorders (SD) are highly prevalent, despite being under diagnosed and under treated in practice. SDs occurs at all ages, although presentation and subsequent consequences for an individual's health varies with aging. Currently, evaluation of SDs are inadequate across all age ranges as they are compromised by under reporting and relying on self-report rather than professional sleep studies (i.e., nocturnal polysomnography (NPS) and multiple sleep latency tests (MSLT)). Moreover, there is a paucity of data specific to the elderly.  Many older individuals report dissatisfaction with quality of sleep.  Indeed, literature has shown that geriatric populations spend less time in slow-wave sleep and rapid eye movement (REM) sleep and have more difficulties maintaining sleep. Their dissatisfaction may occur from changes in sleep architecture associated with the aging process; however, it has been suggested that it largely stems from comorbid illness, social problems, altered circadian rhythms, or side effects of medications that are common in the elderly. Also, geriatric sleep is related to depression, impaired health and functioning, and weaker/ less synchronized circadian rhythms.  In response, we used a 111-item questionnaire in conjunction with NPS, MSLT, the Epworth Sleepiness Scale (ESS) and medical chart reviews of people referred for SD evaluation to compare sleep in geriatrics with adults.  Analysis revealed a numerous differences between adult and geriatric groups, with the elderly experiencing more SDs, longer sleep latencies, and fewer sleep complaints.  Based on the outcomes of this investigation, we posit further consideration to SDs across the age groups to achieve the best health care and quality of life for all.

Key Words: Geriatric, sleep disorders, sleep architecture, quality of life, circadian rhythms

Abbreviations: Sleep disorder (SD), Nocturnal Polysomnography (NPS), Multiple Sleep Latency (MSLT), Epworth Sleepiness Scale (ESS), Rapid Eye Movement (REM).


Figures and Table Count: 
Figures: 0
Tables: 10









Introduction
Sleep disorders (SDs) affect approximately one-third of the world�s population and impact a multitude of physiological and psychological functions [1, 2, 3]. The presence of SDs occurs at all ages, though the presentation and subsequent consequences for an individual's health change in accordance with the natural aging process [4]. At any age, chronic sleep disturbances compromise response times, performance, and short-term memory. These disturbances can have serious consequences for the elderly.  For example, geriatric sleep problems are associated with increased risk of falls, increased depressive/anxious feelings, impaired cognitive functioning and overall poorer quality of life [5]. 
It is commonplace for older individuals to complain that their sleep is not as good as it was when they were younger, as an estimated 50% of adults aged 65 and older experience sleep disturbances [6, 7].  Indeed, aging is associated with changes in average sleep architecture and decreased sleep efficiency. Sleep becomes more shallow and fragmented, less time is spent in slow-wave sleep and rapid eye movement (REM) sleep, and there are more difficulties maintaining sleep [4, 5]. 
It has been suggested that changes in sleep architecture begin in young and middle-aged adults, by slow wave sleep decreasing until reaching a plateau around the age of 60 [5].  However, these changes in sleep architecture do not account for the majority of sleep complaints reported by elderly adults.  Escalating problematic health conditions, use of medications, incidence of depression, amplitude of circadian illness, and social challenges observed in the geriatric population appear to be directly related to sleep disturbances [5, 8, 9].  It is also plausible that the relationship shared by sleep disturbances and health status could be bi-directional, wherein chronic disease contributes to poor sleep and in turn, poor sleep adversely affects the course of chronic disease [8]. Previously it was believed that the amount of sleep needed per night decreases with age.  However, a national survey reports that older adults sleep on average seven hours per night�similar to that of younger adults [7]. Thus, sleep problems may be less attributed to sleep duration, and instead more attributed to the shifting of circadian rhythms.  With age, circadian rhythms become weaker and less synchronized, resulting in different responses to external cues and subsequently less consistent sleep/wake cycles throughout the day [5].  Sleep/wake cycles additionally shift or advance, resulting in complaints of sleepiness earlier in the evening hours, and waking in the earlier hours of morning.  These shifts alone do not account for the disturbed sleep; nevertheless, the attempts of the elderly to maintain what they think is a socially �acceptable� bedtime commonly disrupts sleep.  Indeed, excessive napping and going to bed too late have influential roles in SDs not due to illness or changes in sleep architecture [9].  Napping may further compound sleep problems by reducing sleepiness at the usual bedtime, thus delaying sleep onset and decreasing overall sleep time while contributing to sleep fragmentation at night [9].  SDs not attributed to illness or abnormal sleep architecture may also result from lack of stimulation, diet, or medications that lead to early onset of sleep [5]. 
It is not uncommon for the elderly to ingest numerous medications, both prescription and over-the-counter, typically with one or more contributing to disrupted sleep [5].  Although sedative type drugs can be useful for the relief of temporary insomnia when used occasionally, long-term use may result in habituation, loss of efficacy, drug-induced insomnia, and can gradually begin to imitate the dementia seen in Alzheimer�s disease [4].  Stimulating or alerting drugs that are often taken by older individuals also affect sleep onset at bed time, while the prolonged use of psychotropic/sedative drugs may be associated with familial discord, lower income, poorer health status, depression, and/or anxiety especially in women [5, 10].  It is plausible a bi-directional relationship also exists between mental health drugs and sleep complaints, as poor sleep quality may exacerbate diseases such as depression and anxiety occurring within the geriatric population [8]. It has been reported that sleep disturbances in depressed individuals are commonly a function of the psychiatric disorder [4].
Though the presentations of SDs differ throughout the geriatric population, sex differences further confound clear understanding of SDs in the elderly [8].  It has been postulated that sex differences explain the largest proportion of variance in measures of sleep architecture [11]. The factors that are most strongly related to sex differences in geriatric sleep disturbances are the use of medication, sleep apnea, and marital status [12].  Emerging evidence suggests that bed-sharing impacts sleep quality.  According to the 2005 National Sleep Foundation 61% of adults sleeps with a significant other [13].  People who sleep without a partner have increased delta sleep, and decreased REM sleep [14].  Regardless of actigraphy reports showing more frequent arousals, couples report improved sleep quality when sleeping with a partner [14]. 
In general, women typically have a longer sleep duration and higher sleep efficiency, yet are more likely to report sleep-related complaints, to experience an increased risk of insomnia and to experience psychological effects such as depression and anxiety than their male counterparts [12].  This is evident in the increased association between psychotropic/sedative drug use and women [15]. These trends may be a reflection of gender based psychological and sociocultural factors in addition to genetic and biologic factors [16].  Also, women�s sleep may be more sensitive to relational, marital, and familial status.  Particularly in women, higher rates of divorce coincide with increased rates of sleep disturbances [17]. 
It is plausible that hormonal effects may account for many of the sex differences in elderly sleep [12]. Coinciding with a decrease in estrogen and progesterone levels during menopause, postmenopausal women are more likely to suffer from sleep disturbances. Similarly, decreases in testosterone associated with male aging coincides with decreased sleep efficiency in men [12]. Though it is apparent sex hormones influence sleep in each of the sexes, the mechanism through which this occurs remains unclear and poorly understood. 
Methods
Currently, evaluations of SDs are inadequate across all age ranges because they are compromised by under reporting and relying on self-report data rather than professional sleep studies (i.e., nocturnal polysomnography (NPS) and multiple sleep latency tests (MSLT)).  Moreover, there is a paucity of data specific to older adults.  In response, we constructed a 111-item questionnaire to use in conjunction with NPS, MSLT, the Epworth Sleepiness Scale (ESS) and medical chart reviews of patients referred for evaluation of SDs.  After collection of baseline data, participants were contacted for follow up questions at six months post-sleep study.  After a descriptive analysis comparing geriatric and adult sleep, we examined sex differences to further address characterizations in geriatric sleep.  The study population consisted of 568 adults and 151 geriatrics participants.  All participants were independent adults not living in care facilities.  
Results
We compared SDs and their associates by categorizing participants in two broad age groups: adult (ages 19-65, M= 46.2) and geriatric (ages 66-90, M=71.6) to illuminate a characterization of the geriatric population.  Chi-square analysis and t-tests revealed differences in the associated symptoms of SDs reported between the adult and geriatric groups.  BMI was significantly higher in the adult group (M= 35.2) than the geriatric group (M= 31.7, p< .001).  NPS revealed expected sleep architecture differences specific to the geriatric group spending significantly more time in N1 and less in N3 and REM (see Table 1).  Although the geriatric group had a higher prevalence in SD and physiological diagnoses (see Tables 2-3), experienced longer sleep latencies  and spent significantly less time asleep, they reported fewer sleep related complaints than the adult group (see Table 4). The geriatric group reported fewer bizarre dreams, nightmares, and waking with choking sensations.  Moreover, they reported waking rested more frequently than the adult group.  Day time effects were also less frequent in the geriatric group in areas such as difficulty concentrating, sleep disturbances interfering with social life, and memory/ attention to detail (see Table 5).  Additionally, they experienced fewer headaches (, less anxiety, depression, irritability and stress (see Table 3).
When comparing sex differences in the geriatric group, we found that males spent more time in REM, experienced sleep problems longer before being diagnosed, and experienced more snoring, while females experienced longer sleep latency (see Tables 6-7).  Additionally, more elderly men are married), and more geriatric women report living alone (see Table 8). 
Despite significant differences in physiological comorbidities such as heart attack, body pain, high blood pressure, and thyroid disease; sleep diagnoses did not significantly differ between sexes (see Tables 9-10).  In our population, women more frequently experienced body pain, high blood pressure, anxiety, and had concerns for their mental health. Conversely, men had a higher incidence of breathing cessation, heart attack, and heart failure. This puzzling trend is found across all age groups.
Discussion
These findings indicate that comparison of SDs and their characterizations in the adult and geriatric groups result in both similarities and differences between groups. The adult group had a significantly higher BMI than the geriatric group.  Though it is widely accepted that increased BMI is a contributor to sleep disruptions, we were surprised to find such a stark difference in BMI skewed towards the adult group, despite the geriatric group having a significantly higher prevalence of SDs with other chronic diseases.  This suggests that changes associated with aging may outweigh BMI as a predictor for sleep disturbances.  The most profound differences between adult and geriatric sleep exist in self-reported sleep adequacy.  NPS revealed expected sleep architecture differences specific to the geriatric population spending significantly more time in N1 and less in N3 and REM.  Yet, while the geriatric population experience longer sleep latencies, spend significantly less time asleep, and have a higher prevalence of sleep disorder diagnoses and chronic diseases, they report fewer sleep-related symptomatology (including psychiatric symptoms).  Moreover, the geriatric group reported waking rested more frequently than the adult group.  As sleep quality is related to both psychological and physiological factors, it would follow that future research would benefit from an examination of which is more important for perceived sleep satisfaction.  From our study sample, it would appear that lower levels of psychological distress enhance perceived sleep quality, but do not necessarily positively impact physiological health or recorded sleep quality.  
Further examining sex differences in elderly adults revealed numerous quandaries.  Despite having similar sleep disorder diagnoses, these women reported fewer sleep complaints.  Indeed, unlike men, women were more likely to accept sleep problems as a normal part of life.  Far more geriatric men were married, whereas geriatric women were more likely to be single, divorced, or widowed.  Women in the geriatric group had greater incidences of being diagnosed with physiological health problems and were more likely to be taking a range of medication related to mental health. It is likely that sex hormones have a role in the manifestation and presentation of sleep disturbances in the elderly; however, the modality through which they impact sleep remains unclear.
These results could be a product of under reporting by the geriatric population or perhaps habituation to the challenges associated with sleep disturbances.  It is plausible that the under reporting of geriatric sleep disturbances may be in part attributed to an �ordering� of health issues.  Wherein, perceived higher risk conditions/ chronic diseases such as heart disease, diabetes, or arthritis take precedence in the health concerns of elderly adults while their sleep issues fall to the wayside.  It is also the case that our sample differed dramatically in size (i.e. 151 geriatric cases versus 568 adult cases) which suggests that significantly fewer older adults are referred for sleep studies. We ponder whether this is because sleep complaints by older adults are marginalized, disregarded, or regarded as simply part of the aging process. The intriguing quandaries raised by these results necessitate further examination and consideration. A limitation of our investigation involves the physical health of participants. All participants were individuals living independently; not in a long-term care facility. Inclusions of elderly people living in dependent care would likely result in even poorer sleep and quality of life due to sedentary lifestyle and more severe health status.  We suggest that sleep disturbances across all age groups be given ample consideration to provide the best health care and quality of life for all. 

Table Legend:
Table 1: NPS Sleep Architecture
Table 2: Sleep Diagnoses
Table 3: Physiological/Psychiatric Symptoms
Table 4: Sleep Associated Variants
Table 5: Day Time Symptoms
Table 6: Sex Differences: NPS Sleep Architecture
Table 7: Sex Differences: Sleep Associates
Table 8: Sex Differences: Marital Status***
Table 9: Sex Differences: Sleep Diagnoses
Table 10: Sex Differences: Physiological symptoms







References
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Table 1. NPS Sleep Architecture
AdultGeriatricN1***12.6%18.4%N261.8%60.3%N3*5.2%3.6%REM***15.0%11.58%p*<0.05, p**<0.01, p***<0.001












Table 2. Sleep Diagnoses
AdultGeriatricNocturnal hypoxemia**12.0%21.5%Periodic limb movement disorder**6.1%14.1%Poor sleep efficiency***26.8%45.6%Restless leg syndrome*1.1%3.4%Hypersomnolence*12.8%6.0%p*<0.05, p**<0.01, p***<0.001











Table 3. Physiological/Psychiatric Symptoms
AdultGeriatricAllergies*63.7%54.1%Chronic Lung Disease***12.2%32.9%Diabetes*15.3%22.4%Headaches***70.9%41.7%Heart Attack***6.4%16.4%Heart Failure***7.1%20.7%High Blood Pressure Treatment***36.8%66.7%Nasal/Sinus Problems*43.5%33.8%Stroke***4.8%13.0%Thyroid Disease***16.5%28.4%Anxiety***56.8%41.2%Depression**58.8%45.6%Irritability***76.8%53.3%Stress***83.8%64.6%p*<0.05, p**<0.01, p***<0.001




Table 4. Sleep Associated Variants
AdultGeriatricNPS Sleep Duration (min)***340.2299.4Wake rested***14.9%39.9%NPS Sleep Latency (min)***20.527.7Concerned with well-being**59.8%41.0%Bizarre dreams***51.9%34.1%Choking sensation***39.6%23.2%Feels paralyzed**16.4%6.5%Grinds teeth***29.7%9.1%Nightmares*49.6%36.1%Restroom more than 3x/night***41.5%64.4%Reported sleep latency*27.6%22.0%p*<0.05, p**<0.01, p***<0.001







Table 5. Day Time Symptoms
AdultGeriatricDifficulty concentrating***66.8%38.1%ESS-passenger in car**56.8%45.3%ESS-rest in afternoon**87.4%72.0%Go to bed same time every night* 72.1%87.7%Like to sleep late***65.8%21.1%Oxygen aid while sleeping***7.5%18.5%Sleep interference with social life***61.2%30.4%Take naps***44.7%64.1%Wake at same time every day*66.486.4%Accident due to sleepiness***22.5%7.5%Memory/attention to detail***71.1%56.6%p*<0.05, p**<0.01, p***<0.001







Table 6. Sex Differences: NPS Sleep Architecture
MaleFemaleN119.6%15.5%N258.1%60.8%N32.7%4.6%REM*12.8%10.8%p*<0.05, p**<0.01, p***<0.001












Table 7. Sex Differences: Sleep Associates
MaleFemaleNPS sleep latency (min)**21.637Sleep problem length (years)*11.76.6Snore**86.2%66.7%Stop breathing***77.4%44.2%Arm/leg jerk51.8%34.0%ESS total***11.79.2Fall asleep while driving**25.0%10%Sleep walking**0%4.3%Enjoy sleep*43.3%55.7%p*<0.05, p**<0.01, p***<0.001








Table 8. Sex Differences: Marital Status***
MaleFemaleSingle3.8%7.1%Married80.8%38.6%Divorced3.8%24.3%Widowed7.7%10.8%p*<0.05, p**<0.01, p***<0.001












Table 9. Sex Differences: Sleep Diagnoses
MaleFemaleOSA88.5%81.4%Periodic leg movement14.4%15.7%Poor sleep efficiency51.9%51.4%Abnormal sleep architecture75.0%77.1%Hypersomnolence7.7%2.9%Nocturnal hypoventilation1.0%2.9%Primary snoring10.6%7.1%Restless leg syndrome3.8%2.9%Normal sleep5.8%4.3%Nocturnal hypoxemia19.2%28.6%p*<0.05, p**<0.01, p***<0.001










Table 10. Sex Differences: Physiological symptoms
MaleFemaleAllergies*47.6%64.8%Anxiety*33.7%51.9%Asthma**7.7%18.6%Body Pain**31.3%81.8%Heart Attack*23.1%6.9%Heart burn/acid reflux*32.6%50.0%Heart Failure*25.6%12.1%High Blood Pressure**57.6%81.0%Medication for mental health concerns**26.0%45.7%Thyroid Disease***11.8%55.2%p*<0.05, p**<0.01, p***<0.001

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