doi:10.1111/psyg.
12319
REVIEW ARTICLE
Sleep disorders in the elderly: a growing challenge
1 1
Kamalesh K. GULIA and Velayudhan Mohan KUMAR
1
Division of Sleep Research, Biomedical Technology
Wing, Sree Chitra Tirunal Institute for Medical Sci-
ences and Technology, Trivandrum, India
Correspondence: Prof. Velayudhan Mohan Kumar,
PhD, Sree Chitra Tirunal Institute for Medical
Sciences and Technology, Trivandrum, India. Present
Address: 8A, Heera Gate Apartments, DPI Junction,
Jagathy, Trivandrum, Kerala 695014, India.
Email: wfsrs2005@rediffmail.com
Disclosure: The authors have no conflicts of interest
to declare and did not receive financial support from
any company.
Cognitive Science Research Initiation programme
of the Department of Science and Technology, India
SR/CSRI/102/2014
Received 8 August 2017; revision received 27 October
2017; accepted 15 January 2018.
Key words: circadian rhythm, insomnia, old age,
sleep pattern, sleep rhythm, sleep stages..
INTRODUCTION
The importance of sleep for the overall health and
well-being of the elderly has been increasingly recog-
nized.1,2 Psychiatrists, neurologists, and geriatricians,
general practitioners should have sound knowledge
about the changing pattern of sleep from infancy to
old age. Additionally, the sleep problems faced by
the elderly, and the consequences of inadequate and
inappropriate sleep in determining the quality of their
life, have gained recognition recently.3–7 It is widely
believed that social participation is the key to healthy
ageing. However, data from the US National Social
Life, Health, and Aging Project has shown that older
adults with greater social participation slept better,
but increasing social participation did not improve
sleep.8
The percentage of the elderly population is grow-
ing due to increased life expectancy and improved
© 2018 Japanese Psychogeriatric Society
PSYCHOGERIATRICS 2018; 18: 155–165
Abstract
In contrast to newborns, who spend 16–20 h in sleep each day, adults need
only about sleep daily. However, many elderly may struggle to obtain those
8 h in one block. In addition to changes in sleep duration, sleep patterns
change as age progresses. Like the physical changes that occur during old
age, an alteration in sleep pattern is also a part of the normal ageing pro-
cess. As people age, they tend to have a harder time falling asleep and
more trouble staying asleep. Older people spend more time in the lighter
stages of sleep than in deep sleep. As the circadian mechanism in older
people becomes less efficient, their sleep schedule is shifted forward. Even
when they manage to obtain 7 or 8 h sleep, they wake up early, as they
have gone to sleep quite early. The prevalence of sleep disorders is higher
among older adults. Loud snoring, which is more common in the elderly,
can be a symptom of obstructive sleep apnoea, which puts a person at risk
for cardiovascular diseases, headaches, memory loss, and depression.
Restless legs syndrome and periodic limb movement disorder that disrupt
sleep are more prevalent in older persons. Other common medical problems
of old age such as hypertension diabetes mellitus, renal failure, respiratory
diseases such as asthma, immune disorders, gastroesophageal reflux dis-
ease, physical disability, dementia, pain, depression, and anxiety are all
associated with sleep disturbances.
socioeconomic development. Surprisingly, in the
World Health Organization’s 2015 World Report on
Ageing and Health, there is no mention of sleep dis-
orders.9 In India, the aged population is expected to
be around 20–25% of the population by 2050. By
then, the elderly population would be more than 25%
of the population in developed nations. It already
exceeded 30% in Japan in 2012. The increase in the
aged population will bring with it a huge burden of
sleep-related health problems. Although ageing is a
global phenomenon, little data are available on
regional trends in sleep-related problems.
SLEEP STAGES, TIME, AND
ARCHITECTURE OF DIFFERENT AGE
GROUPS
Behaviourally, sleep is characterized by reduced
motor activity, decreased response to stimulation,
155
K. K. Gulia and V. M. Kumar
stereotyped posture, and relatively easy reversibility.
Scientifically, sleep is defined on the basis of electro-
physiological signals like electroencephalogram
(EEG), electromyogram, and electro-oculogram. The
modern definition and classification of sleep was
suggested initially by Nathaniel Kleitman in 1939, but
it was described in detail in a manual written by
Rechtschaffen and Kales in 1968.10,11 Normal human
sleep was classically divided into rapid eye move-
ment (REM) sleep and non-REM (NREM) sleep, which
consisted of four stages: S1, S2, S3, and S4. How-
ever, the American Academy of Sleep Medicine
slightly modified the staging rules and terminologies
in 2007: S3 and S4 were grouped together as N3,
and S1 and S2 were renamed N1 and N2.12
Sleep starts with a period of NREM sleep (slow
wave sleep) in healthy young adults (Fig. 1). REM
sleep takes place after a short period of NREM
sleep.13,14 This alteration between NREM and REM
occurs about four or five times during a normal
night’s sleep. As NREM sleep progresses to deeper
stages, the EEG shows increasing voltage and
decreasing frequency (Fig. 2). Although muscle activ-
ity is progressively reduced, the sleeper makes pos-
tural adjustments about every 20 min. During NREM
sleep, the heart rate and blood pressure decline, but
gastrointestinal motility and parasympathetic activity
increase. In contrast, REM sleep is characterized by
a profound loss of muscle tone, but the eyeballs
show bursts of rapid eye movements. The EEG
becomes desynchronized during this phase.
Figure 1 Sleep architecture in young adult and elderly. The sleep
pattern of the elderly individual differs from that of the young adult.
In older people, sleep is marked by repeated arousal, reduction in
deeper sleep stages, early sleep onset, and early arousal.
156
Figure 2 Changes in electroencephalogram from awake to slow
wave sleep. The frequency in the electroencephalogram decreases
and amplitude increases as a person goes from stage 1 to stage 4.
The quantity and quality of sleep change pro-
foundly across the lifespan.15 Newborns show sev-
eral sleep–wake cycles over 24 h (Fig. 3). This
polycyclic rhythm passes through a biphasic pattern
before a monocyclic pattern is established by the
time children reach school-age. In newborns, the
total duration of sleep in a day can be 14–16 h. New-
borns spend a large amount of time in active sleep or
REM sleep. Their sleep starts with active sleep
(or REM sleep). Interactions with external synchro-
nizers, such as light, eating, and other sensory
inputs, help them to develop a circadian rhythm. Cir-
cadian sleep–wake rhythm with periodicity in physio-
logical, biochemical, and psychological processes is
modulated by the suprachiasmatic nucleus of the
hypothalamus as well as the pineal gland. These
Figure 3 Sleep pattern as age progresses. The polycyclic sleep
pattern of newborns is converted to a monocyclic pattern in young
adults. An afternoon nap is observed during pre-school age.
Elderly people have a strong tendency for afternoon naps as well.
A shorter span of night sleep is accompanied by early sleep onset
and early arousal.
© 2018 Japanese Psychogeriatric Society

brain areas set the body clock periodicity to approxi-
mately 25 h, but with environmental clues (like light
exposure) and activity schedule, the sleep–wake
rhythm gets entrained to a 24 h day/night cycle.
In young adults, sleep of 7.0–8.5 h is considered
fully restorative.16 The amount of sleep needed by
each person is usually constant, although there is a
wide variation among individuals. During old age,
overnight sleep is often fragmented and lasts for less
than 6.0–7.5 h. The elderly usually have a mid-
afternoon nap for a period of about 1 h. The reason
for these changes in sleep and circadian rhythms
with ageing is not fully understood.
SLEEP CHANGES IN OLD AGE
Changes in the sleep patterns are a part of the normal
ageing process. Older people have difficulty falling
asleep and in staying asleep, due to frequent
arousals. In fact, the required total sleep time remains
nearly constant throughout adulthood. It is only the
sleep architecture and depth that changes with age-
ing (Fig. 1). Older people spend more time in the ligh-
ter stages of sleep (N1 and N2) than in deep sleep
(N3).15,17–19 This results in their waking up several
times during the night. This phenomenon is described
as sleep fragmentation with ageing. In a recent study,
the effect of age on a wide range of variables of sleep,
including total sleep time, percentage of time in each
sleep stage (N1, N2, N3) and REM sleep, arousals
(named as macrostructure), and spectral power
(microstructure), were studied. It showed that ageing
had a more distinct effect on sleep microstructure—a
decline in which was reflected particularly in fast spin-
dle density, K-complex density, and delta power
during N3 sleep—than on conventional sleep staging
variables.20 Some reports indicated an overall
decrease in total sleep time in the elderly.1,18 The
reduction in the percentage of REM sleep is signifi-
cantly correlated with age in women, whereas the
reduction in the percentage of slow wave sleep is cor-
related with age in men.19
REASONS FOR ALTERED SLEEP
ARCHITECTURE IN OLD AGE
The circadian oscillations that alter body functions
including sleep become less pronounced during old
age. This is reflected in the decreased melatonin
© 2018 Japanese Psychogeriatric Society
Sleep in elderly
peak in the elderly (Fig. 4). Older people commonly
exhibit advanced sleep phase syndrome, as they
tend to go to sleep earlier and wake up earlier than
young adults. This could be due to reduced light
exposure. As such, bright light therapy is suggested
as a treatment option for them.
The timing of sleep–wake cycles is regulated by
two interacting regulatory systems: the sleep–wake
homeostatic drive and the internal circadian clock.21
The interaction of these two systems keeps young
adults alert during the day and enables them to
sleep without interruption at night. As people age,
the internal clock becomes less efficient,22 and this
results in interrupted sleep, falling asleep earlier,
and waking up earlier in the morning.23–26 Ageing
reduces the amplitude of circadian oscillation in all
the physiological parameters, including the melato-
nin level.25,27–31 Decline in the efficiency of the cen-
tral master clock—that is, the suprachiasmatic
nucleus in the hypothalamus—is the key element
responsible for this age-related decline. This affects
day/night synchronization in the several peripheral
cellular clocks in the metabolic pathways and endo-
crine mechanism. Circadian rhythms govern not
only the physiological variables such as energy
metabolism, sleep–wake cycles, body temperature,
and locomotor activity, but they also influence the
behavioural systems.32–35 It is plausible that ageing
associated circadian desynchrony is responsible for
metabolic imbalance, central neurodegenerative dis-
orders, and sleep disruptions.36,37 A recent confer-
ence report by Fung et al. discussed in detail the
association between sleep and circadian rhythms
during ageing.38
Figure 4 Alterations in melatonin levels in young adults and the
elderly. There is a marked reduction in the melatonin surge at night
in the elderly. This is probably responsible for the reduction in cir-
cadian variation in many body functions, including sleep.
157
K. K. Gulia and V. M. Kumar

Decrease in EEG delta power is also associated sleep, and is not better explained by another disorder
with difficulties in initiating sleep in old age.39–41 or substance abuse’.54 It is important to note the
Along with the reduction of delta power, the power in emphasis on the perceived dissatisfaction with sleep
the beta waves (an indicator of cortical arousal) is quantity or quality in the second definition. Although
increased in older individuals.39 Age-associated brain polysomnographic assessment of sleep is of much
atrophy and cortical thinning are likely to contribute significance while treating insomnia, it cannot
to these changes.40,42 achieve the desired objective if the patient’s own
feeling about his or her sleep is given due weightage.
The difference in these definitions of insomnia is par-
AGEING PROCESS AT CELLULAR LEVEL tially responsible for the variations in different reports
AFFECTS SLEEP on insomnia.
Ageing in general is a complex process with changes Although the prevalence of insomnia in the elderly
at the molecular, cellular, and genetic levels. A population is high, there is a wide variation in reports
detailed review on the alterations in intercellular com- from different parts of the world (Table 1).55–79 This
munication, cellular senescence, mitochondrial dys- variation cannot be attributed to differences in data
function, deregulated nutrient sensing, loss of from developed and developing nations. Also, the
proteostasis, epigenetic alterations, and genomic variation cannot be attributed purely to differences
instability provides insights into several interlinked between ethnic groups, rural and non-rural popula-
components that are considered hallmarks of the tion, and nursing home and non-nursing home data.
ageing process.35 A progressive loss of physiological A relatively low percentage (15%) of elders has
integrity as well as impaired and deteriorated body insomnia in the Domkhar valley in India’s Ladakh
functioning increase the risk for metabolic disorders,
cardiovascular diseases, neurodegenerative dis- Table 1 Reported prevalence of sleep disorders in aged popula-
eases, and even cancer.19,43–50 Telomeres are the tion (≥60 years) from different parts of the world
chromosomal regions that are particularly susceptible Prevalence Geographical region of
to age-related deterioration.51 Insomnia in older Study group rate aged population
adults (aged 70–88 years) is associated with shorter Foley et al.55 23–34% USA
telomere length in peripheral blood mononuclear Ohayon56 30% France
Maggi et al.57 45% Italy
cells.52 Moreover, sleep disturbances may also Chiu et al.58 38.2% Hong Kong
enhance cellular ageing in the later years of life.52 (Chinese population)
Babar et al.59 32.6% Hawaii
(Japanese Americans)
Kim et al.60 26.4% Japan
INSOMNIA IN THE ELDERLY Pallesen et al.61 38.6% Norway
Insomnia is one of the most common sleep disorders Schubert et al.62 26.4% USA
Sukying et al.63 46.3% Thailand
in the elderly. According to the International Classifi-
Su et al.64 6% Taiwan
cation of Sleep Disorders (3rd edition) by the Ameri- Yu et al.65 10.4% China
can Academy of Sleep Medicine, ‘Insomnia is Bonanni et al.66 44.2% Italy
defined as a persistent difficulty with sleep initiation, López-Torres et al.67 36.1% Spain
Kim et al.68 29.2% South Korea
duration, consolidation, or quality that occurs despite Li et al.69 49.7% China (rural)
adequate opportunity and circumstances for sleep, Tsou70 41% Taiwan
and results in some form of daytime impairment’.53 Ayoub et al. 71 33.4% Egypt
Ford et al.72 21.3% USA
But according to the Diagnostic and Statistical Man- Sagayadevan et al.73 13.7% Singapore
ual of Mental Disorders, 5th edition, ‘insomnia is (Chinese, Malay,
defined as reported dissatisfaction with sleep quan- Indian descent)
Sakamoto et al.74 15.2% Ladakh, India
tity or quality and associated with difficulty with sleep
El-Gilany et al.75 62.1% Egypt (rural)
initiation, maintenance, or early-morning awakening Eser et al.76 60.9% Turkey (nursing home)
and that causes clinically significant distress or Makhlouf et al.77 33.4% Egypt (geriatric home)
impairment, occurs at least 3 nights per week for Gambhir et al.78 32% India (hospital)
Ogunbode et al.80 27.5% Nigeria (geriatric centre)
3 months, occurs despite adequate opportunity for

158 © 2018 Japanese Psychogeriatric Society


region, which is at a high altitude of 2900–4200 m.74
According to some reports, there is a higher preva-
lence of insomnia in the aged in nursing homes and
rural areas.69,75,76 However, other studies have found
no differences in the insomnia patterns of elders in
nursing homes and in other homes.80
The 2004 National Health Interview Survey in the
USA showed that the percentage of elderly men and
women sleeping less than 6 h is as high as
20–25%.81 It has been reported that insomnia is
more pronounced among elderly Hispanics than in
non-Hispanic whites.82 In a small hospital-based
study in northern India, researchers reported insom-
nia in 32% of the elderly population with multiple
comorbidities.78 However, large-scale studies are
required to further understand the role of ethnic dif-
ferences in age-related insomnia. Although insomnia
increases with age, comorbid health conditions
largely influence the clinical severity.
Gender differences in insomnia in the aged popu-
lation cannot be ignored as insomnia is generally
higher in women.43,55–58,61,62,64,66–73 In older women,
with or without symptoms of depression, sleep dis-
turbances increase with age.83 Elevated anxiety is
another culprit that lowers sleep quality.84 It was
reported that the female US veterans (i.e. those who
had served in the armed forces on active duty for a
period of 180 days or more) had a higher risk for
insomnia and sleep-disordered breathing than non-
veteran participants, making them more prone to car-
diovascular diseases and diabetes.85,86 Issues
related to sleep disturbances in postmenopausal
women, especially those coping with osteoarthritis,
have yet to be fully examined.87
SLEEP, DEPRESSION, AND ANXIETY
Good quality sleep is considered a blueprint for
maintaining mental health.88,89 It is well documented
that anxiety and depression are common in the
aged population.83,90 Depression in aged subjects
can lead to adverse outcomes, including impairment
in executive functions, medical illnesses, disability,
increased mortality, and increased health services
utilization.91–93 Accelerated age-related changes in
sleep architecture may be linked to depressed
mood in older adults.94,95 Sleep of short and long
durations are also associated with increased risk of
depression in adults.96
© 2018 Japanese Psychogeriatric Society
Sleep in elderly
Sleep disturbances are regarded as secondary to
depression due to depression’s comorbidity with
sleep disorders. However, recent evidence has indi-
cated that sleep disturbances not only precede the
occurrence of depression, but are also associated
with increased risk for depression cross-sectionally
and longitudinally.88,90,94
SLEEP AND PAIN
Chronic pain is a common debilitating condition
among the elderly population. A national study of
Medicare beneficiaries in the USA showed that both-
ersome pain afflicts half of the older adults, and it
increases significantly with greater disease bur-
den.97,98 This leads to emotional distress, thereby
reducing sleep quality, which in turn can reduce pain
thresholds and increase feelings of fatigue.85 In addi-
tion, symptoms of depression, fatigue, and insomnia
were more severe in subjects with moderate-to-
extreme pain interference than in those who reported
less pain.85 Prevalence of pain and the number of pain
locations are higher in older women than in men.98
SLEEP AND CARDIOVASCULAR DISEASES
Sleeping less than 4–5 h or more than 10 h per night
is linked to increased mortality.99–102 A recent report
on a middle-aged Chinese population found
increased coronary artery disease in those sleeping
less than 6 h per night.103 In a Japanese population,
long sleep duration among the elderly with poor
sleep quality is associated with a higher risk of mor-
tality linked to cardiovascular disease.101 A similar
trend was also observed in aged American
Indians.102 According to this report, cardiovascular
diseases were least prevalent among the subjects
who slept for 7–8 h per night.
SLEEP AND DEMENTIA
Dementia is one the major problematic conditions in
the elderly. A recent meta-analysis and detailed
review indicated that sleep disturbances may predict
the risk of incident dementia. Sleep-disordered
breathing was a risk factor for all-cause dementia,
Alzheimer’s disease (AD), and vascular dementia. In
contrast, insomnia increased the risk for AD but not
for vascular or all-cause dementia.104 Sleep
159
K. K. Gulia and V. M. Kumar
disturbances are common (25–40%) in AD
patients.105 Sleep problems in these patients are a
serious concern as they further adversely affect the
behavioural and psychological symptoms of demen-
tia and also increase the risk factors associated with
patients’ day-to-day activities.106–110 Recent multi-
centric, cross-sectional research in Japan indicated
that sleep disturbances are key early symptoms of
AD associated with behavioural and psychological
factors.111 It was clearly evident from this elegant
study that sleep disturbances were strongly associ-
ated with behavioural and psychological symptoms
of dementia in the very early stage. Very early-stage
AD patients (Clinical Dementia Rating = 0.5) with
sleep disturbances had significantly more behavioural
and psychological symptoms of dementia than those
without sleep disturbances. They also had a higher
prevalence of anxiety, euphoria, disinhibition, and
aberrant motor behaviour. Another study found that
sleep disturbances during middle age are associated
with the development of dementia in later life.112
Cognitive impairment is reportedly increased in older
women with sleep-disordered breathing.113
In recent years there has been substantial progress
in the detection and recognition of dementia with
Lewy bodies (DLB), which has emerged as a common
and important clinical disorder. The DLB Consortium
has also refined its recommendations about the clini-
cal and pathologic diagnosis of DLB. The revised DLB
consensus criteria give increased diagnostic weight-
ing to REM sleep behaviour disorder.114
SLEEP AND PHYSICAL DISABILITY
Physical disability is yet another issue in the elderly
that marks the loss of independence, as difficulty in
performing activities necessary for independent living
increases.115,116 This affects sleep regardless of
whether a person has assistance at home or is in a
hospital intensive care unit.117–119 For those who
have assistance at home, there are genuine concerns
that their caregiver’s sleep is also affected.120
OTHER MEDICAL CONDITIONS
CONTRIBUTING TO SLEEP PROBLEMS OF
OLD AGE
One study excluded subjects affected by various
factors that can disrupt sleep such as poor health,
160
primary sleep disorders, and poor sleep hygiene
(e.g. irregular sleep schedules, poor sleeping envi-
ronments). It found that older adults do not experi-
ence excessive daytime sleepiness and the
concomitant need to nap regularly during the
day.121 Nevertheless, the majority of older adults
have significant sleep disturbances, which are
related to a variety of causes. Physical and psy-
chiatric illnesses, and the medications used to
treat them, also contribute towards sleep prob-
lems in old age.122 The prevalence of insomnia is
higher among older adults and is frequently
related to an underlying medical or psychiatric
condition.100,123–128 People with insomnia often
experience excessive daytime sleepiness, difficulty
in concentrating, and significantly reduced quality
of life. Both behavioural therapies and prescription
medications are considered effective means to
treat insomnia. Reports have suggested that
addressing the conditions of depression and cog-
nitive impairment in the elderly population may
help improve not only their quality of life but also
reduce insomnia.129,130
Snoring, which is most commonly associated with
being overweight and having anatomical alterations
in the upper airway, worsens with age. Loud snoring
can be a symptom of obstructive sleep apnoea, a
condition in which breathing stops for as long as
10–60 s. A drop in oxygen in the blood during this
period alerts the brain, causing a brief arousal (awak-
ening) and breathing resumes. Repeated stoppages
of breathing cause multiple sleep disruptions at night
and can result in daytime sleepiness.47,131
Restless legs syndrome is a neurological disorder
characterized by an irresistible urge to move the
limbs. Prevalence of restless legs syndrome
increases with age and can make it difficult to sleep
through the night. About 80% of people with restless
legs syndrome also have periodic limb movement
disorder. According to the National Sleep Founda-
tion, approximately 45% of all older persons have at
least a mild form of periodic limb movement
disorder.132
Other medical problems can also produce sleep
disorders in old age. Common medical problems
such as hypertension, diabetes mellitus, renal failure,
respiratory diseases (e.g. asthma), immune disorders,
and gastroesophageal reflux disease are all associ-
ated with sleep problems.45,46,49,50
© 2018 Japanese Psychogeriatric Society

NEW APPROACHES TO REMEDIAL
MEASURES
Insomnia is one of the major health issues of old age.
Although this review has not discussed medicines
used for insomnia, it should be noted that classes on
drugs that are commonly used to manage insomnia,
such as benzodiazepines and non-benzodiazepines,
can lead to several residual side-effects like drug
dependence, tolerance, rebound insomnia, muscle
relaxation, hallucinations, depression, and amnesia
on prolonged use.133–135 Consequently, there is a
persistent need to find a safer hypnotics for the treat-
ment of insomnia. Moreover, because of the numer-
ous challenges associated with treating the elderly,
there is an increased need to avoid potentially harm-
ful medications. Treatment with melatonin agonists
has gained popularity because they have a better
safety profile than sedative hypnotics that target
γ-aminobutyric acid receptors.136 Traditional medi-
cines offer a wide range of herbs and herbal products
with sedative properties,137–139 some of which can
be used for prolonged periods without ill effects.
However, because of a lack of scientific validation,
these herbs and herbal products have still not found
a place in the mainstream clinical practice in sleep
medicine.137,138 So it is necessary to evaluate scien-
tifically the hypnotic potential of the active principles
of many of these herbs.140
Non-pharmacologic management of insomnia may
be advisable for many elderly patients. Regular physi-
cal exercise is a simple strategy suggested for dealing
with sleep problems in elders because it may promote
relaxation and raise core body temperature, which
could help in initiating and maintaining sleep.141 One
recent report provided robust evidence for bright light
therapy as a promising non-pharmacological strategy
for managing insomnia in aged subjects with
dementia.142
CONCLUSION
Ageing is associated with increased incidences of
sleep-related ailments. Older people have difficulty in
falling asleep and staying asleep due to frequent
arousals. Changes in sleep patterns are a part of the
normal ageing process, and their caregivers must be
educated about the sleep patterns of the elderly.
Awareness programmes are extremely important and
helpful in dealing with the sleep problems of the
© 2018 Japanese Psychogeriatric Society
Sleep in elderly
elderly. Growing older does not always mean sleep-
ing poorly, but sleeping well can certainly improve
overall health.
ACKNOWLEDGMENTS
This work was supported by research grants from the
Cognitive Science Research Initiative of the Depart-
ment of Science and Technology, India (SR/CSI/110/
2012 and SR/CSRI/102/2014).
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