Insomnia is defined as “a complaint of disturbed sleep in the presence of an adequate opportunity and circumstance for sleep” (Bloom et al., 2009, p. 6). The diagnosis of insomnia requires that the person has difficulty falling asleep for at least 1 month and that impairment in daytime functioning results from difficulty sleeping. Insomnia is classified as either primary or comorbid. Primary insomnia implies that no other cause of sleep disturbance has been identified. Comorbid insomnia is more common and is associated with psychiatric and medical disorders, medications, and primary sleep disorders, such as obstructive sleep apnea or restless legs syndrome. Comorbid insomnia does not suggest that these conditions cause insomnia but that insomnia and the other conditions co-occur and each may require attention and treatment (Bloom et al., 2009). Insomnia has a higher prevalence in older adults and there are many influencing factors, both physiological and behavioral (Box 11-3).

Prescription and nonprescription medications also create sleep disturbances. Drugs and alcohol use are thought to account for 10% to 15% of cases of insomnia (Ham et al., 2007). Problematic drugs include serotonin reuptake inhibitors (SSRIs), antihypertensives (clonidine, beta blockers, reserpine, methyldopa), anticholinergics, sympathomimetic amines, diuretics, opiates, cough and cold medications, thyroid preparations, phenytoin, cortisone, and levodopa. The times of day that medications are given can also contribute to sleep problems—for example, a diuretic given before bedtime or sedating medication given in the morning (Rose & Lorenz, 2010).

The two types of sleep apnea are obstructive sleep apnea (OSA) and central sleep apnea (CSA). OSA, caused by obstruction of the upper airway, is the most common; CSA is due to central nervous system or cardiac dysfunction. Sleep apnea affects an estimated 20% of older men and women in the United States (Rajki, 2012).

In long-term care facilities, the prevalence of OSA has been estimated to be as high as 70% to 80% (Rose & Lorenz, 2010). The age-related decline in the activity of the upper airway muscles, which results in compromised pharyngeal patency, predisposes older adults to OSA. Older adults with sleep apnea demonstrate significant cognitive decline compared with younger people with the same disease severity. The diagnosis of sleep apnea is often delayed in older adults and symptoms are blamed on age (Subramanian & Surani, 2007). Risk factors for sleep apnea are listed in Box 11-4.

The estimated prevalence of RLS among people over 65 years of age is 10% to 20%, and it affects women more than men (Bloom et al., 2009). Other sleep disorders, periodic limb movements of sleep (PLMS), and periodic limb movement disorder (PLMD), are often associated with RLS. These movement disorders of sleep are sometimes called nocturnal myoclonus or periodic leg movements and involve repeated rhythmical extensions of the big toe and dorsiflexion of the ankle. Disrupted sleep is the reason people with these disorders seek help.

Antidepressants and neuroleptic medications can aggravate RLS symptoms. Increased body mass index, caffeine use, tobacco, and sedentary lifestyle are also contributing factors. Diagnosis of RLS includes ruling out and/or treating as indicated any medical condition. Oral iron supplements should be prescribed for patients with serum iron levels lower than 45 μg/L (Winkelman et al., 2007). Dopamine receptor agonists (pramipexole, ropinirole) are the drugs of choice for RLS. Gabapentin may also be effective for individuals with comorbid RLS and peripheral neuropathy (Winkelman et al., 2007; Bloom et al., 2009). Nonpharmacological therapy includes stretching the lower extremities, mild to moderate physical activity, hot baths, and relaxation techniques, and avoidance of alcohol.

Rapid eye movement sleep behavior disorder (RBSD) is a sleep disorder common in older adults. The mean age at emergence is 60 years, and RBSD is more common in males. Characteristics of RBSD are loss of normal voluntary muscle atonia during REM sleep associated with complex behavior while dreaming (Subramanian & Surani, 2007). Patients report elaborate enactment of their dreams, often with violent content, during sleep. This may include violent behaviors, such as punching and kicking, with the potential for injury of both the patient and the bed partner.

RBSD may be primary or secondary to neurodegenerative diseases such as Parkinson’s disease, diffuse Lewy body disease, Alzheimer’s disease, and progressive supranuclear palsy. It may also be idiopathic (Bloom et al., 2009). RBSD may be an early sign of Parkinson’s disease. Within 5 to 8 years of being diagnosed with RBSD, 60% to 80% of individuals develop Parkinson’s disease (Brooks & Peever, 2008). Caffeine and some medications (SSRIs, tricyclic antidepressants) may also contribute to RBSD. Interventions include neurological examination, removal of aggravating medications, and counseling related to safety measures in the sleep environment. Clonazepam and/or melatonin may be effective in treating RBSD.

A combination of good sleep hygiene practices and methods to delay the timing of sleep and wake times are recommended as treatment for ASPD. Bright light therapy (2500 to 10,000 lux) for 1 to 2 hours at about 7 to 8 PM can help normalize or delay circadian rhythm patterns (Bloom et al., 2009).

In ISWD, the individual may obtain enough sleep over the 24-hour period, but time asleep is broken into at least three different periods of variable length. Erratic napping occurs during the day, and nighttime sleep is severely fragmented and shortened. Chronic insomnia and/or daytime sleepiness are present. ISWD is most commonly encountered in individuals with dementia, particularly those who are institutionalized. Sleep disturbances of individuals with dementia are often among the reasons for nursing home placement. Treatment consists of increasing the duration and intensity of light exposure during the daytime and avoiding exposure to bright light in the evening. Structured activity during the day and a quiet sleeping environment may also improve ISWD (Bloom et al., 2009).