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Sleep structure is qualitatively and quantitatively changed by aging. The elderly usually go to bed in early evening and wake up in early morning, and they also take several naps in the day time. The polyphasic sleep is one of the typical sleep patterns found in the elderly. Comparing the sleep of the elderly with that of young adults by the method of polysomnography, the characteristics of the sleep of the elderly are in the prolongation of sleep latency, shortening of total sleep time, increase of Stage W and Stage 1, decrease of Stage 3 and 4, and also decrease of Stage REM and the advance of REM phase. Insomnia is a frequently observed symptom in the elderly. The so-called psychophysiological insomnia due to transient psychological or situational stress is common in the elderly. However, insomnia following the mental disturbance (depression), chronic use of drug or alcohol, dementia (vascular or Alzheimer type) are also important in the elderly. Sleep apnea syndrome is recently found as an important cause of insomnia. Concerning the treatment and prevention of insomnia, it is necessary to exclude the causes of insomnia, to improve the environmental conditions and to keep the regular rhythm of sleep-wake cycle. It is also important to carefully select and use the adequate hypnotics considering the pharmacokinetics and adverse effects of the drugs in the elderly.
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PMID:[Sleep disturbance in the elderly]. 219 Nov 61

Because sleep needs vary from person to person, insomnia is defined as the chronic inability to obtain the amount of sleep needed for optimal functioning and well-being. Insomnia, which is a symptom rather than a disease, can be classified into three main etiologic groups: insomnias related to other mental disorders (for example, depression and anxiety), insomnias related to known organic factors (for example, sleep apnea and "nonrestorative" sleep), and primary insomnia (for example, learned psychophysiologic insomnias and insomnia complaints without objective findings). The treatment for insomnia often involves a combination of pharmacotherapy, behavioral and short-term psychotherapy, and sleep hygiene guidelines. Sleep disorders centers can provide specialized knowledge and techniques for patients with severe chronic insomnia.
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PMID:Insomnia. 219 48

The diagnosis of obstructive sleep apnea is frequently made by taking a meticulous history coupled with a high index of suspicion. Snoring and hypersomnolence are clinical features common to individuals with sleep apnea. Since snoring is said to be a "disease of listeners," it is not uncommon that bed partners reported an increased incidence of depression and marital displeasure. It is for this reason that the spouse or bed partner should be interviewed, since the patient may not be aware of any sleeping problems. Physicians should also be alert to complaints of excessive daytime somnolence, because studies have shown that patients with obstructive sleep apnea are at increased risk for automobile crashes. It has been estimated that approx 58,000 motor vehicle accidents involving people with sleep apnea will occur in the US each yr. By proper diagnosis and treatment, the physician is in a unique position to prevent at least some of the automobile accidents that result from falling asleep while driving. Polysomnography is the only definitive way to obtain a diagnosis of sleep apnea. This allows the physician not only to diagnosis the disorder, but also helps in the evaluation of the severity of the syndrome and selection of therapy. An ENT evaluation is also important in ruling out anatomic disorders that can cause upper airway obstruction. Certain factors, such as alcohol and sedative ingestion, may aggravate the condition in a person predisposed to sleep apnea, and subtle changes, such as unexplained hypertension, polycythemia, and cor pulmonale, should lead one to investigate the possibility of sleep apnea as the etiology.
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PMID:Diagnosis of obstructive sleep apnea. 229 95

Despite its widespread use, the validity of the 5/h morbidity cut-off for the Respiratory Disturbance Index (RDI) or the Movement Index (MI) in determining presence of sleep apnea (SA) or sleep-related periodic leg movements (PLMs), respectively, has not been determined for any aged population. One hundred community resident seniors 60 years of age or older underwent three consecutive nights of polysomnography and also completed conventional measures of subjective sleep-wake complaints (written sleep questionnaire, sleep log, sleep interview) and mood disturbances (Zung Self-Rating Depression and Anxiety Scales, Profile of Mood States, Beck Depression Inventory). Based on the 5/h cut-off, 34% had SA and 58% had PLMs. Despite this, the frequency of subjective sleep-wake and mood disturbance was low across methods of assessment. Groups formed by the 5/h cut-off for RDI or MI failed to differ significantly in responses on all subjective sleep-wake and mood measures. Higher cut-offs also were examined and proved weak or ineffective in predicting subjective sleep-wake and mood disturbance. Preliminary investigations suggested that alternative measures of severity of SA (means oxygen desaturation and means duration of apneas or hypopneas) may be better predictors of subjective disturbance than RDI in this population. These findings both (a) demonstrate that the polygraphically identified SA and PLMs which are widespread in seniors tend not to be manifested in self-reported sleep-wake or mood disturbance, and (b) illustrate the need for validated morbidity cut-offs for SA and PLMs.
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PMID:Morbidity cut-offs for sleep apnea and periodic leg movements in predicting subjective complaints in seniors. 233 Apr 74

In 1984-85, 1855 elderly residents of an urban community responded to a comprehensive baseline interview that included questions regarding an extensive set of sleep characteristics and problems. During the subsequent 3 1/2 years of follow-up, 16.7% of the respondents died and 3.5% were placed in nursing homes. The predictive significance of each sleep characteristic for mortality and for nursing home placement was determined separately for males and females, using Cox proportional hazards models. Selected demographic and psychosocial variables were also entered into the models. Age, problems with activities of daily living (ADL), self-assessed health, income, cognitive impairment, depression and whether respondents were living alone were controlled for statistically. Of the many variables analyzed, in males insomnia was the strongest predictor of both mortality and nursing home placement. For mortality, the relative hazard associated with insomnia exceeded the hazards associated with age, ADL problems, fair-poor health and low income. For nursing home placement, the hazard associated with insomnia exceeded that associated with cognitive impairment. The relationships of insomnia to mortality and nursing home placement were U-shaped, with a worse outcome if insomnia complaints over the preceding 2 weeks were either prominent (numerous or frequent) or absent. For females, insomnia was a borderline predictor of mortality and did not predict nursing home placement at all. Symptoms of the restless legs syndrome predicted mortality for females in some Cox regression models. Reported sleep duration, symptoms of sleep apnea and frequent use of hypnotic drugs did not predict mortality or nursing home placement in either sex.
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PMID:Sleep problems in the community elderly as predictors of death and nursing home placement. 235 10

Alcohol and benzodiazepines may increase sleep-disordered breathing by decreasing activity of pharyngeal dilating muscles, favoring the development of obstructive apneas and hypopneas. Narcotics cause greater depression of wakeful respiration than the previously mentioned drugs; however, the influence of narcotics on the upper airway and breathing during sleep has not been studied. We, therefore, examined, in 12 healthy adults, the effects of oral hydromorphone hydrochloride (2 and 4 mg) on breathing during sleep and on a variety of awake respiratory variables (minute ventilation, gas exchange, and chemoresponsiveness). In addition, awake pharyngeal inspiratory airflow resistance was determined before and after narcotic administration to assess the drug's influence on patency of the upper airway. Following both doses, minute ventilation decreased, and carbon dioxide pressure increased. The 4-mg dose of hydromorphone hydrochloride also produced a significant decrement in the hypoxic ventilatory response, whereas hypercapnic responsiveness and pharyngeal resistance did not change following either dose of the drug. Despite the respiratory depression during wakefulness described previously, no significant change was observed in any measure of sleep-disordered breathing after either dose of narcotic. We conclude that in healthy individuals without suspected sleep apnea, oral hydromorphone in standard dosages does not significantly increase sleep-disordered breathing. This result may be due to a lack of selective depression of upper-airway muscular function by the doses of narcotic used.
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PMID:Effects of oral narcotics on sleep-disordered breathing in healthy adults. 243 98

We present the case of a 63 years old man (177 cm height, 111 kg weight) with autoimmune thyroiditis. He had a long term history of hypersomnolence and heavy snoring. Two years ago, because of a bifascicular block and sinus pauses, a cardiac pace-maker was placed. Polysomnography recording showed a systematic periodic breathing characterized by profound desaturation waves (often 92% Sa O2 to 60% Sa O2) every 60 seconds, secondary to prolonged mixed apneas. Hormone replacement therapy and a 17 kg weight loss completely suppressed the sleep apnea syndrome within five months. We conclude that SAS is a major component of the respiratory depression in hypothyroidism and that normalisation of thyroid function can definitely cure the patient.
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PMID:[Sleep apnea syndrome and hypothyroidism: apropos of a new case and a review of the literature]. 265 40

The syndrome of obstructive sleep apnoea is associated with an increased morbidity (the consequence of diurnal hypersomnolence and cardiovascular complications). The contraction of the dilator muscles of the upper airways (nose and pharynx) allows their patency at the time of inspiration. The obstruction of the airways resulted in a disequilibrium between the forces which tend to their collapse (negative inspiratory transpharyngeal pressure gradient) and those which contribute to their opening (muscle contraction). The mechanisms which underlie the triggering of obstructive apnoea are multiple including a reduction in the calibre of the superior airways, an increase in their compliance, and a reduction in the activity of the muscle dilators. This latter is intimately linked to the respiratory muscles and these muscles respond in a similar manner to a stimulation or a depression of the respiratory centre. The ventilatory fluctuations observed during sleep (alternately hyper and hypo ventilation of periodic respiration) thus favours an instability of the superior airways and the occurrence of oropharyngeal obstruction. The depth of post-apnoeic desaturation depends on the value of the arterial oxygen saturation at the beginning of apnoea, the duration of the period of apnoea and the pulmonary volume as the period of apnoea passes off. The cardiovascular consequences of apnoea include disorders of rhythm (bradycardia, auriculoventricular block, ventricular extrasystoles) and haemodynamic (pulmonary and systemic hypertension). This results in a stimulatory metabolic and mechanical effect on the autonomic nervous system. The electroencephalographic awakening which precedes the easing of obstruction of the upper airways is responsible for the fragmentation of sleep. The factors implicated in the cessation of the apnoea include hypoxia and hypercapnia but one also invokes a role for the negative pressure generated during the course of the apnoea.
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PMID:[Physiopathology of obstructive sleep apneas]. 269 Feb 8

Insomnia is a disorder of initiation and maintenance of sleep that results in daytime somnolence. The differential diagnosis of the various forms of insomnia is based primarily on the history, including information from the sleeping partner. The possibility of underlying depression or sleep apnea must be given consideration in every patient with insomnia, because inappropriate therapy may be dangerous in these instances. In general, the benzodiazepines have supplanted the traditional hypnotics in the treatment of insomnia.
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PMID:Diagnosis and treatment of insomnia. 288 77

Sleep and respiration studies were carried out in 12 subjects (9 males, 3 females) at an altitude of 4,800 metres, during effect of a French expedition in the Himalayas. The effect of loprazolam, a hypnotic benzodiazepine, was investigated in a double-blind, 2 parallel group, 1 mg loprazolam versus placebo trial. Sleep was evaluated by means of electroencephalographic recordings and questionnaires. The effects of altitude in each subject were intercurrent wakefulness increase, slow wave sleep and paradoxical sleep decrease and nocturnal periodic breathing. The mean duration of sleep apnea episodes was 12 seconds with a maximum of 24 seconds. These episodes occurred during stages 1 or 2 of sleep and during paradoxical sleep. Female subjects exhibited less periodic breathing than males. Acclimatization to high altitude increased total sleep time, stage 3 duration and percentage of paradoxical sleep. Loprazolam tended to decrease stage 2 latency and did not worsen slow wave sleep depression or episodes of apnea. Normal amounts of slow wave sleep and intrasleep wakefulness appeared in the loprazolam group after acclimatization.
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PMID:[Periodic respiration during sleep at high altitude. Effects of a hypnotic benzodiazepine, loprazolam]. 289 61


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