Clinical Assessment of Children and Young People with Sleep Problems and Co-Morbid Neurodevelopmental Disorders

*Michael O. Ogundele, Chinnaiah Yemula and Hani F. Ayyash*

## **Abstract**

Sleep disorders are very common among children and young people (CYP) with neurodevelopmental, emotional, behavioural and intellectual disorders (NDEBID). NDEBID include several conditions such as Attention Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), Cerebral palsy (CP), Epilepsy and Learning (Intellectual) disorders. Extant literature have reported up to 80% of CYP with NDEBID experiencing different types of chronic insomnia, compared to 3–36% of their otherwise normally developing counterparts. Sleep disorders among CYP with NDEBID have severe negative consequences on the affected individuals and their families. Chronic sleep deprivation causes behavioural, memory and attention problems, mood disorders, impaired cognitive development, learning abilities, and school performances. It also significantly increases the stress level and impact the wellbeing of other family members and impair family cohesion. Sleep disorders therefore further aggravate both internalising and externalising behaviours, emotional wellbeing and daily functioning of CYP with NDEBID. This chapter provides a brief summary of the various important aspects of sleep physiology, aetiology, classification and prevalence of sleep disorders among CYP with NDEBIDs. It outlines various behavioural, non-pharmacological management strategies and pharmacotherapy. Practical tips for clinicians are outlined in an easy-to read flow chart, including sections on assessment, investigations, care plan formulation and follow-up.

**Keywords:** sleep, emotional, neurodevelopmental disorders, pharmacotherapy, non-pharmacologic interventions, cognitive therapy, insomnia, melatonin, children, adolescents, psychoeducation

## **1. Introduction**

Sleep problems affects all age group of children from preschool age to adolescence, with a prevalence of up to 80% reported among children and young people (CYP) with Neurodevelopmental (and related Neurodisability), Emotional, Behavioural, Intellectual and Disorders (NDEBID). This is disproportionately higher than the prevalence of 3–36% among typically developing children and adolescents [1, 2].

The prevalence of sleep disorders in CYP with NDEBID is also related to the degree of their disability. For example the prevalence of sleep disorders among adolescents with learning disability varies between 26% for moderate disability to 44% for severe disability. This compares with prevalence of 15–19% among adolescents with no disability [1].

Sleep disorders among CYP with NDEBID have severe negative consequences on the affected individuals and their families. Even among normally developing CYP, chronic sleep deprivation causes behavioural problems, impaired cognitive development and learning abilities, poor memory and attention problems, mood disorders and impaired school performances [3–5]. It also increases the risk of other health outcomes, such as obesity, cardiovascular, immunity, growth and metabolic consequences [6, 7]. It also significantly increases the stress level and impact the wellbeing of other family members and impair family cohesion [8]. Sleep disorders therefore further aggravate and exacerbate both internalising and externalising behaviours, emotional wellbeing and daily functioning of CYP with NDEBID. Appropriate management of sleep disorders ameliorate the short-term health and emotional consequences, optimization of daily functioning, family cohesion and prevention of psychiatric pathology in later adulthood [4, 9].

This chapter provides a brief summary of the extant literature on various important aspects of sleep physiology, aetiology, classification and prevalence of sleep disorders among CYP with NDEBIDs. It outlines various strategies for the management of sleep disorders, including behavioural non-pharmacological strategies and pharmacotherapy. Practical tips for clinicians managing CYP with co-morbid NDEBID and sleep disorders are outlined in an easy-to read flow chart, including sections on assessment, investigations, care plan formulation and follow-up.

## **2. What are neurodevelopmental (and related neurodisability), emotional, behavioural, intellectual and disorders (NDEBID)?**

NDEBID is the umbrella terminology used in this chapter to refer to common childhood developmental disorders including several related conditions such as Attention Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), Cerebral palsy (CP), Epilepsy and Learning (Intellectual) disorders. Childhood NDEBID such as ADHD, tic disorder/Tourettes syndrome, developmental delay, development coordination disorder.

These conditions constitute a group of congenital or acquired long-term conditions that are attributed to disturbance of the brain and or neuromuscular system and create functional limitations in sensory, motor, speech, language, cognition or behaviour [10, 11]. They often co-occur together and co-morbidities are the rule rather than exceptions. Prevalence of up to 15% for NDEBID have been reported in developed countries, based on varying methodologies and definitions [12, 13]. They are best managed by specialist Paediatricians or Psychiatrists working within integrated teams involving other allied healthcare professionals, education, social care and voluntary sectors [14–16].

## **3. Sleep physiology in NDEBID**

### **3.1 Definition and normal physiology**

Sleep is a reversible state of reduced awareness of and responsiveness to the environment. There are two main phases of sleep: Rapid Eye Movement (REM) and *Clinical Assessment of Children and Young People with Sleep Problems and Co-Morbid… DOI: http://dx.doi.org/10.5772/intechopen.112031*

Non-REM [17]. Rapid eye movement (REM) sleep is prominent in early infancy, possibly explaining in part why sleep seems to be fragile at this age. Deep NREM sleep is particularly prominent in early childhood, and this is one of the reasons why arousal disorders (such as sleep walking) occur mainly at this stage [18].

#### **3.2 What are the benefits and ideal sleep duration for children and adolescents?**

Sleep is essential for optimal growth, emotional and cognitive development CYP. A group of experts from the American Academy of Sleep Medicine and the National Sleep Foundation have published recommendations for the sleep duration required by different age groups of CYP to refresh and rejuvenate the body and mind (**Table 1**).

Chronic sleep deprivation is associated with attention, behaviour, and learning problems, increased risk of accidents, injuries, hypertension, obesity, diabetes, and depression, as well increased risk of self-harm, suicidal thoughts, and suicide attempts among teenagers [19]. CYP and their carers require regular encouragement and emphasis about the benefits of adequate sleep, including improved attention, behaviour, learning, memory, emotional regulation, quality of life, mental and physical health (**Table 2**). Parents can help their children by monitoring their sleep pattern and encouraging them to see professionals for help.


#### **Table 1.**

*Recommended sleep duration for each age group.*


#### **Table 2.**

*Benefits of adequate sleep and negative consequences of inadequate sleep.*

## **3.3 Aetiology and pathogenesis of sleep disorders in NDEBID**

The aetiology of sleep disorders in children with NDEBID is multifactorial and could also be disease specific. These include are biologic, behavioural (including environmental) and psycho-medical factors [20]. There is limited high-quality data and clinical guidelines to help offer a consistent approach to diagnosis and management of sleep disorders among CYP with NDEBID and co-morbid sleep problems [21]. **Table 3** shows common causes and examples of sleep disorders.

The most common sleep disorders among CYP include chronic sleep deprivation, delayed sleep phase disorder (especially among teenagers), difficulty falling asleep or maintaining sleep, and early morning [9, 22].

### **3.4 Classification of sleep disorders**

Several terminologies and sometimes conflicting definitions of sleep disorders have been published, in terms of age, frequency, severity, and duration of symptoms. We refer to the definitions in both the 5th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [18] and the 3rd edition of the International Classification of Sleep disorders (ICSD-3) [23] as reference standards in this chapter. Paediatric insomnia has been defined as "repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite age-appropriate time and opportunity for


*(P) Parent-directed question (C) Child-directed question. Source: Mindell JA, Owens JA. A Clinical Guide to Paediatric Sleep (Diagnosis and Management of Sleep Problems), Lippincott Williams & Wilkins 2003.*

*\*[B = bedtime problems; E = excessive daytime sleepiness; A = awakenings during the night; R = regularity and duration of sleep; S = Snoring].*

#### **Table 3.**

*Outline of 'BEARS'\* screening questions.*

*Clinical Assessment of Children and Young People with Sleep Problems and Co-Morbid… DOI: http://dx.doi.org/10.5772/intechopen.112031*

sleep and results in daytime functional impairment for the child and/or family" [6]. **Table 4** refers to a slightly modified ICSD-3 classification of sleep disorders.

#### **3.5 Prevalence of sleep disorders in NDEBID**

The commonest NDEBID mostly associated with sleep disorders include Autism spectrum disorder (ASD), Attention deficit hyperactivity disorder (ADHD) and Learning disabilities. Sleep disturbance is reported to be the second most common comorbidity in children with ASD, with estimated prevalence between 33 and 81% [22, 24]. They often experience coexisting emotional problems such as anxiety or depression and epilepsy [25–27].

Common effects of sleep disturbances in CYP with ASD include increased severity of autism symptoms, challenging daytime behaviour such as physical aggression, emotional disturbances such as irritability, inattention, and hyperactivity [24, 28]. Several factors that may account for sleep disturbances associated with autism include alterations in neurotransmitter release, such as serotonin and melatonin, impaired


#### **Table 4.**

*ICSD-3 classification of common sleep disorders.*

sensory sensitization, behavioural insomnia syndromes, delayed sleep phase syndrome, abnormal rapid eye movement sleep, decreased time in bed, increased proportion of stage 1 sleep [25, 26].

Up to 70% of CYP with ADHD also have significant sleep problems including behavioural insomnia (limit-setting disorder), bedtime resistance, latency of sleep onset, dim light melatonin onset delay, decreased duration of sleep, increased number of overnight awakenings, and daytime somnolence sleep-disordered breathing, and restless legs syndrome/periodic limb movement disorder [29]. Their sleep disturbances may also be due to side-effects of ADHD medications [30]. Sleep problems among ADHD CYP can be transient and variable over time in up to 60% but can be more persistent in another 10% of the population [31]. Sleep problems can present with increasing severity of ADHD symptoms, poorer child quality of life (QoL), daily functioning and caregiver mental health, poor school performance and attendance [32]. It is important to emphasise that sleep disorders are identified before diagnosing ADHD, since disordered sleep can manifest with symptoms that mimic ADHD such as inattention, problematic behaviour, and poor emotional regulation [30].

## **4. Management of sleep disorders in CYP with NDEBID**

#### **4.1 Published clinical guidelines**

There is limited global evidence-based clinical guidelines available to practitioners managing CYP with NDEBID [21]. Some professional bodies have produced multidisciplinary national consensus statements for the use of their members [7]. The American Academy of Neurology has also recently published treatment guidelines specifically addressing individuals with autism spectrum disorder [33]. The authors have published a proposed evidence-based flow chart practice guidance for managing sleep problems among CYP with NDEBID [34].

#### **4.2 Clinical assessment**

Clinical assessment with detailed medical, social, family, academic and lifestyle history including sleeping pattern and physical examinations during routine health encounters with CYP by all health practitioners should be undertaken as a standard procedure due to high prevalence of sleep problems in this population, especially among those with any NDEBID conditions [35, 36]. The diagnosis of sleep disorders in CYP is essentially clinical and should include information provided by the parents/ caregivers and the older children and young people [7].

Sleep history should include the sleep/wake schedule, sleeping environment and bedtime routines, abnormal movements or behaviour during sleep, and lifestyle effects of sleep deprivation, daytime sleepiness, sleep onset latency and nighttime interruptions (**Box 1**) [2, 37].

Validated sleep questionnaires such as BEARS screening Assessment (see **Table 3**) and Children's Sleep Habit Questionnaire (CSHQ) are useful adjuncts to clinical assessment. The goal of detailed clinical assessment should be identification of a specified sleep disorder or of potential differential medical or anatomical diagnosis (**Table 4**). Detailed history about current medical conditions and medications should be recorded to determine possible effects on the sleep cycle (**Table 5**). Some coexisting medical conditions that may disturb sleep include Asthma, Eczema,


#### **Box 1.**

*Components of detailed sleep assessment history.*


#### **Table 5.**

*Some medications that can influence the sleep cycle.*

Gastroesophageal reflux, Epilepsy, Chronic pain and Rheumatological conditions, and emotional problems like Anxiety, Depression and Mood disorders.

It should be noted that rare conditions like Narcolepsy and nocturnal Epilepsy are more commonly experienced co-morbidities among CYP with NDEBID [38].

#### **4.3 Investigations**

Baseline investigations required for formulation of a management plan include a 2-week sleep diary and actigraphy [9]. Actigraphy is a technical device used for

monitoring body motion, sleep and wake patterns in individuals, that can be carried out in their home environment. It can measure sleep parameters such as total sleep time (TST), sleep efficiency, wake after sleep onset, and sleep onset latency (SOL), help to determine sleep patterns and document response to treatment in the patient's normal sleep [7].

Polysomnography (PSG) is a more comprehensive sleep study involving recording of sleep and other related physiological parameters from multiple electronic sensors, often combined with video recordings, carried out in specialist centres. PSG is particularly useful for diagnosis of sleep-related breathing disorder, atypical parasomnia, Periodic Limb movement disorder (PLMD), clinically unconfirmed Restless leg syndrome (RLS) or nocturnal seizures [39].

#### **4.4 Common differential diagnosis and treatments**

Detailed assessment should lead to formulation of a sleep disorder diagnosis or consideration of potential differential diagnosis including as follows:

#### *4.4.1 RLS and PLMD*

Common causes of childhood onset RLS include familial predisposition and systemic iron deficiency. Treatment options include iron supplementation and Gabapentin (researched mainly in adults). PLMD is a sleep disorder that is characterised by periodic and repetitive movements of legs and less often arms during sleep. Restless sleep disorder in childhood is a recently proposed entity, characterised by night-time restlessness, daytime sleepiness, and often iron deficiency, despite not meeting the diagnostic criteria for RLS or PLMD [17]. There is inconclusive research evidence for use of iron therapy, Dopamine agonists and anticonvulsants for RLS and PLMD in children [36].

#### *4.4.2 Parasomnias*

Parasomnias are undesirable physical activities predominantly associated with sleep. They are classified according to the dominant sleep phase during which they occur: rapid Eye Movement (REM), Non-REM and Non-specific. REM parasomnias include sleep paralysis, hallucinations and REM behaviour disorder. Non-REM parasomnias include confusional arousals (often triggered by sleep apnoea, RLS, or acid reflux), sleep walk and night terrors. Parasomnias often respond to reassurance and safety measures, with use of pharmacotherapy with benzodiazepines reserved for severe, potentially dangerous cases, and administered by sleep specialists [40].

#### *4.4.3 Obstructive sleep apnoea*

Obstructive sleep apnoea (OSA) is often caused by physical phenomenon such as adeno-tonsillar hypertrophy, cranio-facial anomalies, and obesity. The prevalence among CYP is estimated to be 2 percent and it is a common indication for urgent of children referral to the ENT surgeons [41].

#### *4.4.4 Delayed sleep phase syndrome (DSPS)*

Delayed Sleep Phase Syndrome (DSPS) is commonly diagnosed among male adolescents and associated with normal sleep pattern which is delayed by more than

*Clinical Assessment of Children and Young People with Sleep Problems and Co-Morbid… DOI: http://dx.doi.org/10.5772/intechopen.112031*

2 hours relative to socially acceptable conventional sleep times. It can be treated with chronotherapy, light therapy and potentially melatonin as long as the patient is motivated [42].

## **5. Comprehensive management of sleep disorders among CYP with NDEBID**

A comprehensive clinical assessment should lead to the formulation of a sleep plan with graduated behavioural and pharmacological therapy and specialist referrals where indicated. The plan needs to be reviewed at regular intervals until a desirable sleep pattern has been achieved. A flow chart of recommended practice guidance is outlined in **Figure 1**.

## **5.1 Non-pharmacological/behavioural strategies**

There is ample published evidence to recommend behavioural interventions as the first line treatment of sleep disorders, including practice of sleep hygiene, parent and care-giver education and training and behavioural interventions alternative therapies (such as massage therapy, aromatherapy, nutrients and multivitamin or iron supplementation) and Cognitive Behaviour Therapy (CBT) for older children and adolescents [9, 21, 26, 43].

### *5.1.1 Behavioural strategies*

There is sufficient evidence to support the short- to medium-term effectiveness of cognitive-behavioural strategies based on learning principles, for the management of paediatric insomnia [7, 44]. The most popular behavioural interventions are different

**Figure 1.**

*Recommended flow chart for sleep management guidance based on the published evidence.*

types of extinction: either complete (total removal of reinforcement to reduce a behaviour) or various degrees of graduated measures (including bedtime fading/positive routines and stimulus control techniques) and scheduled awakenings). The definitions and practical tips of cognitive behaviour strategies are listed in the **Table 6**.

## *5.1.2 Parent-training and psychoeducation*

Psychoeducation is the process of empowering CYP and their carers by providing them with practical information regarding their sleep problems, with a systematic, structured and didactic approach [45, 46]. This enhanced understanding of their condition enables them to implement self-management strategies and effective partnership with professionals and improved compliance with prescribed treatment, resulting in more desirable outcomes. **Table 7** presents a list of some useful resources for parents and young people with sleep problems.

## *5.1.3 Good sleep hygiene*

"Sleep hygiene" refers to healthy sleep habits and practical strategies that promote optimal sleeping patterns. They typically involve modifiable daytime, bedtime, and night-time practices such as diet, exercises and sleeping environment, with insufficient evidence to be recommended as stand-alone therapy [9, 37, 47]. Practical examples include use of reward charts, objects of reference such as applying parents pyjamas or perfume on teddy bear, pink or white noise (or music), night or daytime indicators such as Glo-clock or side lamps (**Box 1**).

## *5.1.4 Cognitive behaviour therapy (CBT)*

CBT is a common psychological treatment that helps to modify negative thoughts and behaviours through structured conversation between the professional and the patient. There is scientific evidence that supports cognitive-behavioural treatment as the most effective intervention in the management of sleep disorders, especially for older adolescents and young people [7, 48].

## *5.1.5 Neurofeedback*

Sensori-Motor Rhythm (SMR) and Slow-Cortical Potential (SCP) neurofeedback have been identified to produce some beneficial effects in improving sleep onset latency, especially among CYP with ADHD [49].

## **5.2 Pharmacological treatment**

Pharmacotherapy is often considered as second line treatment after cognitivebehavioural strategies alone have not been effective.

## *5.2.1 Melatonin*

Melatonin is a natural hormone produced by the pineal gland in the brain. It controls the body's circadian cycles which corresponds to the ambient 24 hour light– dark period, for such as sleep/wake rhythms, blood pressure, body temperature and metabolism [50]. The main effects of administered Melatonin include chronobiology


**Table 6.** *Behavioural*

*interventions*

 *to improve sleep in children with chronic insomnia.*

*Clinical Assessment of Children and Young People with Sleep Problems and Co-Morbid… DOI: http://dx.doi.org/10.5772/intechopen.112031*


#### **Table 7.**

*Some useful resources for parents and adolescents.*

*Clinical Assessment of Children and Young People with Sleep Problems and Co-Morbid… DOI: http://dx.doi.org/10.5772/intechopen.112031*

(circadian phase-shifting) and hypnosis (sleep-promotion). Melatonin also has some immune modulating properties and should be avoided in individuals with compromised immune functioning [51].

There is ample published evidence to support the use of melatonin in treating CYP with NDEBID. The reported benefits of moderate doses of melatonin (up to 6 mg) include reduced sleep onset latency and number of awakenings/night, and increase in total hours of sleep/night [52–54], but it has no significant benefit in reducing the number of awakenings per night [54], and has limited effect on Child behaviour and family functioning [55]. Melatonin is more likely going to be effective for children who are sleeping less than 6 hours at night [56]. However, there is a paucity of evidence on managing sleep disturbances in CYP with NDEBID specifically [57].

Most slow-release melatonin formulations (mainly Circadin) are licenced for adults with primary insomnia, but are widely used "off-label" to treat sleep disorders among CYP of all ages [58]. The European Medicines Agency has recently licenced a melatonin brand (Slenyto) for CYP with Autism and Smith Magenis syndrome [59]. The U.S. Food and Drug Administration recognises Melatonin as a supplement which therefore does has not require its *approval*. Melatonin is generally considered to be safe for short-term management of sleep disorders among CYP, but its long-term safety have not been extensively studied [60]. CYP on melatonin require regular re-evaluation to ensure the treatment is terminated as soon as it is no longer required [50].

The effectiveness of melatonin can often diminish overt time, due to decreased the CYP1A2 liver enzyme activity, either genetically determined or due to the effect of other medications [61]. In patients with loss of response to melatonin, a period of melatonin clearance for up to 3 weeks and a considerable dose reduction has been advised [20].

#### *5.2.2 Antihistamines (alimemazine, promethazine, diphenhydramine, hydroxyzine)*

Antihistamines constitute the most popular prescribed agents for managing sleep problems among CYP with sleep problems, despite limited research evidence to support their efficacy. Clinicians should be aware that some sedative antihistamines, such as hydroxyzine or diphenhydramine can present with paradoxical agitations in children, and their effects on sleep latency duration is very minimal [54].

#### *5.2.3 Alpha 2 adrenergic agonists (clonidine and Guanfacine)*

Clonidine and Guanfacine are examples of alpha-2-adrenergic receptor agonist, whose mechanism of action for sedation remains elusive. They are commonly prescribed for CYP with co-morbid ADHD and associated sleep disorders, but the research evidence to support their effectiveness is very scanty [49, 62]. In a USA National survey, alpha agonists were the most commonly prescribed insomnia medication for children with ADHD (81%) [63].

#### *5.2.4 Z-drugs (zopiclone, eszopiclone, zaleplon and zolpidem)*

Z-drugs are approved and commonly prescribed for transient sleep disorders in adults. Only few studies have been carried out regarding effectiveness among CYP, with contrasting results, and report of increased adverse effects compared to melatonin [37, 55].

#### *5.2.5 Benzodiazepines (like clonazepam and Flurazepam)*

Benzodiazepines are sedative medications which are not routinely recommended for treatment of sleep disorders in children, except for limited periods to alleviate comorbid daytime anxiety [37]. Clonazepam has been advocated for treatment of severe parasomnia/night terrors under specialist supervision [47].

#### *5.2.6 Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants*

Use of selective serotonin reuptake inhibitors (SSRIs) such as Sertraline may be considered for disabling bedtime anxiety. Tricyclic antidepressants, used in adults with insomnia, are not approved for CYP due to their poor safety profile [47]. While Trazodone and mirtazapine have potential benefits, they require further evidence for routine prescription for children with NDEBID [37]. Trazodone may be effective in managing sleep disorders among children with Angelman syndrome with specialist advice from a tertiary sleep centre [47].

## **6. Alternative therapies**

There is a plethora of herbal and other over-the-counter formulations that have traditional been used for self-management of sleep disturbances, based on anecdotal assumptions. These include Valerian, Lavender, Chamomile and Kava products [7].

## **7. Combined treatment modalities**

Only limited studies have assessed the efficacy combining behavioural and pharmacological therapies. The combination of controlled-release melatonin over 12 weeks and four sessions of cognitive-behavioural therapy among a group of ASD Children aged 4–10 years, showed a trend to outperform other active treatment groups, with fewer dropouts and a greater proportion of treatment responders achieving clinically significant changes [64].

A similar small Canadian study among 27 ADHD children reported the effect size of the combined sleep hygiene and melatonin intervention from baseline to 90 days' posttrial was 1.7, compared to 0.6 on average for either sleep hygiene or melatonin alone. However, the decreased sleep latency and improved sleep had no demonstrable effect on ADHD symptoms [65].

## **8. Referrals to relevant specialist**

Considering the limited resources and varied expertise in clinical practice, it is important for clinicians to have a low threshold to make an onward referral whenever a significant sleep disorder is suspected. The referral pathways/practice policies need to be agreed locally among all the major Clinicians and stakeholders [39].

Sleep disorders that often require further evaluation by a specialist include suspected OSA, PLMD, debilitating parasomnias and narcolepsy. Referrals should be made to a relevant specialist such as an ENT surgeon (in case of suspected OSA) or a *Clinical Assessment of Children and Young People with Sleep Problems and Co-Morbid… DOI: http://dx.doi.org/10.5772/intechopen.112031*

Respiratory physician/sleep centre for suspected severe parasomnias, PLMD or narcolepsy [17].

## **9. Conclusion**

Children and young people with neurodevelopmental disorders experience higher prevalence of sleep difficulties and sleep disorders compared to the general population. In addition to other associated comorbidity, this can negatively affect their cognitive development, behaviour, physical and mental health. There is also significant negative impact on their peer- and family-relationships.

In view of the high prevalence of associated sleep problems, clinicians should screen for sleep disorders when assessing all children and adolescents with cognitive, behavioural, and emotional problems. It is important to undertake a comprehensive evaluation, including use of clinical tools such as BEARS questionnaire, Child Sleep Habit Questionnaire, a 2-week sleep diary, actigraphy and relevant physical examination, in order to identify the sleep pattern and diagnose and any underlying potential sleep disorders.

Due to the complex nature of underlying comorbidity, social, cognitive and psychological difficulties, it is often a frustrating journey for parents/carers to achieve a good quality of sleep for CYP with NDEBID. Initial steps in management involve providing parents/carers and CYP with user-friendly psychoeducation and sleep hygiene measures, taking into account the individual and family circumstances. Specific behavioural interventions where appropriate can be implemented as first line management for sleep disorders.

In CYP with NDEBID and insomnia, use of melatonin should be carefully considered only following an unsuccessful trial of sleep hygiene and behavioural measures, while persevering with the appropriate sleep hygiene measures. Referrals should be made to relevant specialist/sleep centre for further assessment and management of severe sleep disorders, including OSA, PLMD and narcolepsy.

## **Conflict of interest**

The authors declare no conflict of interest.

## **Abbreviations**


*Sleep Medicine – Asleep or Awake?*

## **Author details**

Michael O. Ogundele<sup>1</sup> \*, Chinnaiah Yemula<sup>2</sup> and Hani F. Ayyash3,4,5,6

1 Department of Community Paediatrics, Bridgewater Community Healthcare NHS Foundation Trust, Halton District, UK

2 Department of Community Paediatrics, Cambridgeshire Community Services NHS Trust, St Ives, Cambridgeshire

3 Essex Partnership University NHS Foundation Trust, Essex, United Kingdom

4 Children's Health Services, Southend-On-Sea, United Kingdom

5 British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, London, United Kingdom

6 Child and Adolescent Psychiatry Surveillance System, Royal College of Psychiatrists, London, United Kingdom

\*Address all correspondence to: m.ogundele@nhs.net

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Clinical Assessment of Children and Young People with Sleep Problems and Co-Morbid… DOI: http://dx.doi.org/10.5772/intechopen.112031*

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## **Chapter 5**

## Common Sleep Problems and Management in Older Adults

*Pak Wing Cheng and Yiu Pan Wong*

## **Abstract**

Sleep problems are common among the elderly due to physiological changes and comorbid psychiatric and medical conditions. Sleep architecture changes with age. However, sleep disturbances among older adults should not be seen barely as a result of ageing. Depression and anxiety are important differential diagnoses for elderly patients complaining of sleep disturbance. Dementia and delirium are also common causes of sleep disturbances among older people. Elderly people often carry several medical comorbidities. These medical conditions can both lead to and be exacerbated by sleep problems. Given the frailty, multimorbidity and vulnerability of some of the elderly, the management of sleep problems requires additional considerations compared with younger adult patients. Behavioural modifications and drugs of choice will be discussed.

**Keywords:** elderly, sleep disturbance, insomnia, geriatric psychiatry, insomnia management

## **1. Introduction**

Sleep problems are common in the elderly population. A recent meta-analysis study suggested that the prevalence of pooled sleep disturbance was up to 35.9% in older Chinese adults [1]. Another study in Italy suggested that insomnia was observed in 44.2% of subjects aged 65 or above [2]. While causes of sleep disturbance among the elderly are multi-folded, it is clear that female gender, depressed mood and physical illnesses are general risk factors for sleep disturbance in the geriatric population [3]. Other less robust risk factors in this age group identified by different studies include low physical activity level, low economic status, loneliness and perceived stress [3]. Mild cognitive impairment, long-term use of sedative drugs and high inflammatory markers are also possible predicting sleep disturbance factors [3]. While psychical health issues can affect sleep, poor sleep, in turn, can exacerbate mood and medical problems, causing a vicious cycle. For example, Eguchi et al. [4] demonstrated in their study that short sleep duration is an independent predictor of stroke among the elderly with hypertension. It was also suggested that difficulties in initiating sleep and maintaining sleep in people aged 75 or above were associated with an increased risk of falls, which is a particular worry for elderly people [5]. Poor sleep is closely related to cognitive decline and the mental health of elderly people. However, these problems are often unaware by medical professionals or not optimally

and timely managed. The following paragraphs aim to present a general picture of sleep problems in senior groups.

## **2. Sleep cycle and pattern of the elderly**

Studies have shown that amount of sleep and sleep architecture change with age. On the one hand, total sleep time, deep slow-wave sleep and sleep efficiency (the ratio of total sleep time to time in bed) decrease with age [6]. A more recent study done by Schwarz et al. [7] on elderly women further suggests that ageing was associated with lower fast spindle and K-complex density in N2. On the other hand, the duration of light sleep increases with age, with elderly people being more easily awakened by external stimuli and resulting in sleep fragmentation [8, 9]. In a study done by Ohayon and Vecchierini [10], the median night-time sleep duration of elderly people aged 60 or above was about 7 hours, with no significant difference found among different sub-age groups of these elderly people. The authors suggested that a short total sleep time was associated with obesity, poor health and cognitive impairment [10]. Therefore, short sleep time and insomnia among the elderly population should not be attributed to ageing alone [10–12].

Advanced sleep phase syndrome is another key feature of elderly sleep patterns [9, 13]. Elderly people tend to go to sleep and wake up earlier compared with young adults. Biologically, this can be a result of the decrease in the suprachiasmatic nucleus(SCN) volume and cell count and a decrease in melatonin secretion [13, 14]. Various other physiological malfunction processes at the cellular and systematic levels also contribute to circadian desynchrony and alternation of sleep patterns among elder people [13]. Psychosocially, advanced sleep phase syndrome can also result from lifestyle changes after retirement and subsequently reduced light exposure [8, 13]. With a generally more sedentary and less social lifestyle, there is little drive for older adults with advanced sleep phase syndrome to reschedule their bedtime [8].

## **3. Insomnia and mood disorders among the elderly**

#### **3.1 Insomnia**

Insomnia is the predominant sleep problem found among the elderly population. While there are no well-recognised diagnostic criteria or classification systems dedicated to insomnia disorder in the senior age group, a general framework for insomnia can be used in the encounter with elderly patients. According to DSM-5, insomnia disorder refers to dissatisfaction with the quality and quantity of sleep that cause distress or impairment in daily function [15]. To fulfil the diagnostic criteria of insomnia disorder, one has to experience sleep difficulty despite sufficient chances to sleep, and the sleep difficulty should last for at least three days a week [15]. Sleep difficulty could arise from difficulties in falling asleep (sleep initiation), frequent awakening and difficulty in returning to sleep (sleep maintenance) or early-morning awakening (late insomnia) [15]. Sleep fragmentation is common in the elderly population, especially those with dementia. Demented patients, as mentioned below, are also subject to early morning awakening.

Insomnia disorder can be classified according to its chronicity and aetiology. According to the International Classification of Sleep Disorders (ICSD)-Third

#### *Common Sleep Problems and Management in Older Adults DOI: http://dx.doi.org/10.5772/intechopen.111656*

Edition, insomnia is considered chronic for over three months [16]. ICSD classifies the aetiology of insomnia into primary and comorbid [16]. Similarly, DSM-5 includes specifiers of insomnia according to the comorbid conditions, i.e. with non-sleep disorder mental comorbidity, with other medical comorbidity and other sleep disorders [15]. Elderly patients are subject to multiple comorbidities and polypharmacy. Insomnia is a common result of these chronic conditions. Therefore, the diagnosis of chronic insomnia is better reserved for patients for whom insomnia is especially prominent, unexpectedly prolonged and is one of the foci of treatment plans [16]. Pharmacological treatments for chronic insomnia in the elderly should be prescribed with caution in view of the possible serious side effects of certain drugs among elderly patients (see below).

As with other psychiatric conditions, the causation of insomnia can be understood in terms of biological mechanisms and psychosocial aspects. The two-process model of sleep–wake regulation depicts the roles of melatonin and adenosine, which regulate circadian rhythm regulation and sleep–wake homeostasis, respectively [17]. Dysregulation of the circadian rhythm can lead to difficulty in sleep initiation and early morning awakening, while dysregulation of sleep–wake homeostasis may lead to sleep initiation and maintenance difficulties [17]. Cajochen et al. [18] suggested that age-related changes in sleep structure are mainly due to a reduction of circadian force. At a neural circuitry level, the reticular activating system that comprises cholinergic, monoaminergic, histaminergic and glutamatergic neurons is responsible for wakefulness, in contrast to the GABAergic neurons that promote sleep [17]. Pathology in the relevant neural substrates may explain insomnia in patients with Parkinson's disease and possibly Alzheimer's disease [19]. Some scholars suggest that monoamines could be the link between REM sleep and depression [20]. However, as with the case of dementia, the exact neural mechanisms between insomnia and mood disorders are yet to be clarified.

In terms of psychosocial aspect, the 3 P models, i.e. predisposing, precipitating, and perpetuating factors, can be used to understand the course of insomnia in elderly people.

#### *3.1.1 Predisposing factors*

As mentioned above, some demographic factors are reported to be related to an increased risk of sleep disturbances. Many of these factors are also predisposing factors for insomnia, including female gender and lower socioeconomic status, and physical and mental health illness [21]. Divorced couples and widowers also have a high prevalence of insomnia [21]. This agrees with the findings mentioned above that loneliness is associated with sleep disturbance [3]. Family history of insomnia, poor sleep hygiene, stress, poor sleep environment, low physical activity level and use of substances are other predisposing factors that clinicians should consider [21–23]. Loss of a spouse and low physical activities are also relevant concerns for elderly people.

#### *3.1.2 Precipitating factors*

New onset or deterioration of medical and mental illnesses can precipitate insomnia in the elderly. Symptoms and worrisome brought by medical diseases can affect sleep quality. Hospitalisation, and certain drug use, such as decongestants and steroids, also precipitate insomnia [23, 24]. Psychological stressors and stressful life events that precipitate insomnia include financial problems, changes in living environment, e.g. moving to nursing homes, and the death of loved ones [24, 25].

#### *3.1.3 Perpetuating factors*

Perpetuating factors are behavioural and cognitive changes that occur after the onset of diseases and prolong an acute insomnia episode into chronic problems [23]. Patients with insomnia may take frequent naps that compensate for short or poor night's sleep. Besides, they may stay awake for a prolonged time in bed due to difficulties falling asleep [23]. These maladaptive behaviour changes can prolong and worsen the problem of insomnia. From the cognitive aspect, patients may be worried or even anxious about not being able to fall asleep, which further worsens insomnia [23]. A vicious circle is formed, and patients may eventually rely heavily on medications to treat insomnia.

#### **3.2 Sleep, depression and anxiety**

Sleep disturbances, mainly insomnia, are common symptoms of depressive disorders and general anxiety disorder. A recent longitudinal study on middle-aged and older people suggested a bidirectional relationship between short sleep duration and depression [25]. Several other studies also indicated that perceived poor sleep quality correlates with depressive and anxiety symptoms among elderly people [26–28]. Therefore, depression and anxiety are important differential diagnoses for elderly patients who present with sleep disturbance.

### *3.2.1 Late-life depression*

The presentation of depression in elderly people may be different from that among younger adults. Elderly people may be less likely to complain of low mood than younger adults. In contrast, they may show more irritability, anxiety and somatic symptoms [29]. Also, non-demented elderly patients with depression may present like cognitive impairments [30]. Indeed, a close relationship between depression and cognitive functions in elderly people has been reported. Depression is found to be associated with the occurrence and progression of neurocognitive disorder [31, 32]. Physical health-related risk factors of depression among older adults include chronic diseases, especially vascular-related diseases, disability and self-perceived health [33]. Several mechanisms have been proposed to explain the biological basis of late-life depression. The vascular depression hypothesis suggests that cerebrovascular diseases or cerebrovascular risk factors can lead to depression [34]. The hypothesis is supported by imaging studies and the fact that depression is more common in post-stroke patients [29, 34]. The inflammation hypothesis suggests that the persistent activation of microglia and inflammatory response within the brain lead to an imbalance in the cytokines system and subsequently lead to neuronal death and reduced neuroplasticity [34]. Psychological risk factors of depression among elderly people include maladaptive coping strategies and negative self-image [33].

#### *3.2.2 Generalised anxiety disorder*

A recent study done in a multicentre setting suggested that the prevalence of generalised anxiety disorders was about 3.1% in the elderly [35]. Although not all studies suggested a strong co-occurrence between generalised anxiety disorder and depression in the elderly population, there is a high overlap in the symptoms between the two disorders and co-occurrence in the clinical population [35, 36]. Elderly patients

with GAD may also present with frequent somatic complaints with unexplained symptoms [36]. The biological and psychological risk factors of anxiety and depression show significant similarities [33]. It has also been suggested that elderly patients with GAD may progress to depression [36, 37]. Therefore, the clinician should screen for depression in patients the present with symptoms of generalised anxiety disorder, including sleep disturbances. Deteriorated physical health and life events can lead to worrying in elderly people. Clinicians need to identify excess, uncontrollable and unrealistic worrying of elderly people that may suggest anxiety disorders [36].

## **4. Neurocognitive disorders**

The decline in cognitive functions is common among the elderly population. Mild cognitive impairment (MCI) refers to a syndrome where one's experiences cognitive decline more significant than expected with regard to one's age and education while activities of daily living are not notably interfered with [38]. Dementia, in contrast, refers to a great extent of cognitive decline severe enough to affect daily living [38].

Sleep problems are common in people with MCI and dementia, particularly in patients with Alzheimer's disease (AD) and Lewy body dementias (LBD) [39]. The elderly with different types of dementia may present with different kinds of sleep disturbance. Sleep disturbance is a predictor of more severe cognitive and neuropsychiatric symptoms and poorer quality of life [39]. However, it does not mean that the longer the sleep duration, the better for the demented patients. Indeed, results from a meta-analysis suggest that too short (i.e. less than 5 hours) and too long sleep duration (i.e. longer than 9 hours) also correlated with the poor cognitive performance of various domains, including executive function, as well as verbal and working memory [40].

#### **4.1 Alzheimer's disease**

Alzheimer's disease is the most common and well-known cause of dementia worldwide [41]. Pathogenesis of the diseases involved amyloid plaque and neurofibrillary tangle formation that is associated with neuronal loss and cognitive decline in affected patients [42]. Common psychiatric symptoms are apathy, followed by depression, aggression, anxiety and sleep disorder [43]. Of note, about 40% of AD patients experience sleep disorders [43].

Sleep problems of people with AD can present in different ways. One of the common presentations is significant sleep fragmentation, i.e. more frequent and longer period of intra-sleep wakefulness [44]. Although awakening is not the most common sleep disturbance among AD patients, it brings the most disturbance to caregivers [45]. Factors associated with night-time awakening include male gender, more severe memory and functional deficit [45]. Other sleep problems include daytime sleepiness and early morning weakness [44, 45]. Some patients experience a shift in sleep–wake rhythm; in extreme cases, the patients may exhibit day/night sleep pattern reversal [46]. However, in end-stage AD, patients may appear to sleep throughout the day with brief periods of awakening [46].

Sundowning, referring to an increase in behaviour disturbances in demented patients late in the day, is common among patients with AD [46]. Sundowning can begin in the later afternoon or early evening. Sundowning behaviour includes agitation, reduction in attention, disorganised speech, motor disturbance like wandering, hallucinations and emotional disturbances, e.g. anxiety and anger [46]. Sundowning itself

reflects a disturbed diurnal rhythm of the affected patients, and improving the nocturnal sleep problem of the patients may alleviate the symptoms of sundowning [46].

Studies have also suggested that altered sleep duration, sleep fragmentation and insomnia are associated with risk of MCI and AD [39]. Although it is not sure whether sleep disturbance is an early marker of cognitive impairment, or causes cognitive impairment, good sleep seems to be a protective factor against AD [39].

#### **4.2 Lewy body dementias**

Lewy body dementias refers to dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PD-D) [47]. Hypersomnia is common in patients with Lewis body dementias due to nocturnal sleep fragmentation, sleep apnea, periodic limb movement and change in sleep–wake physiology [47]. For PD-D, other behavioural features associated with PD-D include apathy, loss of motivation, change in personality and psychosis [48]. Visual hallucinations are more common than other sensory modalities of hallucination and are usually complex, e.g. seeing people, objects and animals [48]. Delusions are usually paranoid in nature or phantom border [48].

The clinical features of DLB and PDD are similar. Similar to PD-D, patients with DLB may also experience detailed and well-formed visual hallucinations of people, animals or objects [49]. DLB patients may present with daytime drowsiness and disorganised speech [49]. Fluctuations in cognition, attention and arousal are typical characteristics of DLB [49]. A core features of DLB are REM sleep behaviour disorder (RBD) which may precede cognitive decline [49]. RBD can lead to significant injuries that require hospitalisation, yet its prevalence may have been underestimated [50].

#### **4.3 Sleep-disordered breathing and cognitive impairment**

Both obstructive and central sleep apnea prevalence increase with age [51, 52]. The prevalence of sleep-disordered breathing (SDB) is higher in men than women, yet the difference disappears in the elderly age group [52, 53]. Cognitive impairments are also common in patients with sleep-disordered breathing. Studies suggested that obstructive sleep apnea is associated with neurodegeneration and pathological process closely related to Alzheimer's disease [53]. A study done in a multicentre setting in Italy also showed that around 60% of patients with different degrees and types of neurocognitive impairments had SPD [54]. In fact, elderly people with obstructive sleep apnea are associated with a range of medical conditions in addition to cognitive decline. These medical conditions include cardiovascular diseases, stroke, chronic pulmonary diseases and depression [55]. While the metabolic mechanisms behind it are not well defined, OSA leading to intermittent hypoxemia, followed by sympathetic activation, sleep fragmentation and sleep deprivation, are believed to be part of the reasons. Diagnosis of OSA in elderly patients is easily missed, partly due to the non-specific symptoms. Some of these presentations are common in elderly people without OSA, including nocturia, gait disturbance, and post-operative delirium. Other symptoms may mimic other neurological and psychiatric conditions, including limb movement during sleep, fragmented sleep, mood disturbance and daytime attention.

While daytime sleepiness is one of the key presentations of OSA, studies have shown that daytime sleepiness is less common among elderly patients compared with younger patients [56]. Although continuous positive airway pressure (CPAP) has been proven to be effective in improving symptoms of OSA, its acceptance among elderly

patients is reported to be low. Studies in Asia showed that CPAP is not accepted by a majority of elderly patients [57, 58].

## **5. Medical diseases and sleep disturbance**

Multimorbidity is a characteristic of patients in the older age group. Medical diseases can lead to sleep disturbance in several ways. Symptoms of medical diseases disturb sleep (**Table 1**). Besides, medical diseases can precipitate mood disorders that further worsen sleep problems. Sleep problems, in turn, can worsen disease outcomes. Examples include stroke [62], diabetes mellites [64] and cardiovascular diseases [65]. The relationships among medical disease, mental illness and insomnia can be complex. One example is chronic pain in elderly people. Chronic pain is common in elderly people. Chronic pain can directly lead to sleep and psychological distress. Studies suggested that chronic pain is strongly associated with depressive and insomniac symptoms among the elderly [66, 67]. On the other hand, patients with depressive symptoms with or without insomnia are more likely to experience distress from pain [67]. A more recent study that looked into the temporal relationship between insomnia and chronic pain suggested that insomnia could be a risk factor for chronic musculoskeletal pain, with depressive symptoms bearing a partial mediating effect [68].



#### **Table 1.**

*Common medical diseases and related symptoms or conditions in elderly people that disturb sleep.*

Elderly patients may not volunteer sleep problems when seeing doctors for medical diseases. For the sake of holistic care and a better outcome for medical diseases, sleep problems should be considered to ask during consultation for relevant elderly patients, especially in primary care settings.

## **6. Delirium**

Delirium refers to an acute deterioration of attention, cognition and consciousness. Delirium is common in elderly people in admission, especially in the ICU setting [69]. While old age is a predisposing factor for delirium, older adults can bear multiple predisposing factors that make them vulnerable to delirium. These predisposing factors include underlying cognitive impairment, sensory deficits, comorbidities and low functional state [70]. Common precipitating factors for delirium include medication, particularly polypharmacy and use of psychoactive drugs, infection, bladder catheter, electrolytes and metabolite disturbance, trauma and surgery [70]. Sleep and delirium are highly related. One of the key supporting features of delirium sleep–wake cycle disturbance, while sleep deprivation can predispose to delirium [69, 70]. Poor sleep environment and circadian misalignment in hospitals therefore can contribute to delirium in elderly people in admission [69]. Drug choice for delirious patients is important. Opioids, sedating and hypnotic drugs, including benzodiazepine and anticholinergic, can precipitate delirium [69, 70]. Although antipsychotic and sedative drugs may reduce agitation and behavioural symptoms of patients, these medications may turn patients with hyperactive delirium into hypoactive delirium [70]. Hypoactive delirium tends to be under-recognised by clinicians and has poor survival outcomes [70, 71]. Therefore, non-pharmacological treatment and reduction of the insulting drugs should always be considered first and maximised in delirious patients [69, 70].

## **7. Clinical approach**

#### **7.1 Diagnosis and screening**

The rest of the chapter focus on the clinical approach and management of older adults with sleep disturbance. The general clinical approach for sleep disorders in elderly is illustrated in **Figure 1**. Sleep complaints can be related to 1) sleep pattern, 2) quantity, 3) sleep quality and 4) underlying causes for sleep disturbance.

1.Sleep pattern Sleep: Disturbance can occur at different time points throughout sleep. Starting from the onset of sleep, elderly people may complain of advanced *Common Sleep Problems and Management in Older Adults DOI: http://dx.doi.org/10.5772/intechopen.111656*

**Figure 1.** *General approach for elderly people with sleep disturbance.*

or delayed sleep phase syndrome. Some elderly people may even show a daynight reversal sleep pattern or stay awake for most of the night. Elderly patients may experience sleep latency, i.e. difficulty in falling asleep. In the middle of sleep, patients may experience difficulties in maintaining sleep and easy awakening, i.e. sleep fragmentation. Towards the end of sleep, early morning awakening can signify neurocognitive disorders or mood disorders.


Several screening tools can be considered for symptom evaluations (**Table 2**).

## **7.2 Non-pharmacological management**

## *7.2.1 Non-pharmacological Management for Insomnia*

A wide range of management options for insomnia is listed in **Table 3**. Several nonpharmacological managements can be considered in elderly patients with insomnia. Cognitive behavioural therapy for insomnia (CBT-I) is recommended as a first-line treatment for chronic insomnia [82]. CBT-I should also be always considered for


#### **Table 2.**

*Screening tools for elderly people with sleep problems.*

elderly patients, yet, there are more challenges during implementation and flexibility is required [81]. CBT -I consist of psychoeducation, relaxation therapy, cognitive therapy and behavioural strategies, which include sleep restriction and stimulus control [82]. For sleep education, elderly patients should be advised to construct a daily sleep routine and avoid going to bed too early [81]. As mentioned before, the sleep advancement phase is common in elderly people, partly due to psychosocial reasons. Elderly people be encouraged to set a sleep schedule to prevent going to bed too early. A comfortable and suitable sleep environment is essential. For hospitalised or institutionalised elderly people, sleep disruptions from the sleep environment should be minimised. Night-time lighting, bed restraints, TV noise or interference from other patients are common causes that disturb wards or nursing home sleep environments [81, 85]. For patients staying in nursing homes, caregivers can decorate the sleep environments with objects that elderly people are familiar with [85]. For example, elderly people can bring their own pillows, blankets or other personal belongings with them to nursing homes [85]. Lifestyle changes imported for elderly people include ensuring regular daytime physical activities and avoiding prolonged napping [81, 85]. For stimulus controls, elderly patients should not stay in bed or bedroom in case of difficulties in falling asleep. However, due to pain or immobility, implementing stimulus control can be difficult [81]. Sitting up patients, listening to music, reading and other non-stimulating activities can be carried out instead [81]. Similarly, sleep restriction is effective but difficult to be carried out in institutionalised elderly people or those who are ill [81].


*CBT = cognitive behavioural therapy; GABA = γ-Aminobutyric acid; SSRI = selective serotonin reuptake inhibitors; SNRI = serotonin and norepinephrine reuptake inhibitors.*

### **Table 3.**

*Main treatment choices for elderly people with sleep disturbance.*

Sleep restriction can aim to reduce the total time spent in bed by 20–30 minutes every week to increase sleep efficiency [81]. Cognitive behaviour therapy can also be used to treat underlying mood disorders related to sleep problems. Cognitive sleep therapy can improve symptoms of anxiety disorders [86, 87], although the reported effectiveness varies and is not superior to medication. CBT may also show a decreased effectiveness in elderly patients with anxiety and cognitive impairment [86].

Light therapy has been proposed for elderly people with sleep problems. However, the effectiveness of light therapy on elderly people with sleep disturbance was in doubt. While a systematic review done showed light therapy brings little benefit for elderly people with primary insomnia [80], a more recent meta-analysis supported the efficacy of light therapy in treating geriatric nonseasonal depression [88]. Studies also suggested that bright light therapy can compensate for circadian rhythm alternation in demented patients [89]. However, evidence for light therapy for the treatment of elderly sleep disturbance is not strong and should be considered as an adjunct therapy [82].

### *7.2.2 Considerations for caregivers of patients with cognitive impairments*

Frontline healthcare professionals should advise caregivers on handling sleeprelated problems in elderly people with MCI or dementia. Elderly people with MCI or dementia may wander around at night, even leaving their living place at midnight. The following advice may be helpful for caregivers of these elderly people, for example, their family members [85]: 1. adopting an accepting attitude. Caregivers should avoid direct conflicts with elderly patients. Direct conflicts may agitate the elderly. Instead, caregivers can start the communication with an open-ended question, e.g. "How can I help you with", or "What are you looking for?"; 2. Orienting the elderly patient with environmental cues. Caregivers can show the patients a clock or bring them near the windows to orient them to time; 3. Following the elderly patient and confining the time and place of wandering. Sometimes the patients may exhibit a strong wish to leave their living place for their "home". It may not be easy for caregivers to stop them. In those situations, caregivers will have to follow the elderly patient. The caregivers can try to communicate with the elderly and set an agreed area and duration of wandering.

It is worth mentioning that sleep problems are not only common among elderly patients with dementia, but also among their caregivers. Night-time awakening and short total sleep of patients significantly impair caregivers' sleep [46]. Taking care of demented patients can mount significant mental stress on caregivers. The stress comes from the heavy workload of taking care of the patients and the patient's behaviour disturbances [46, 85]. Therefore, caretakers are prone to mental health problems, including insomnia, comorbid anxiety and depression [85]. Caregivers may present with mood disturbance, somatic complaints, feeling of guilt, suicidal ideation or aggressive behaviours towards the patients [85]. Given that demented patients are often seen together with their caregivers in the clinical settings, frontline healthcare workers should beware of the signs and symptoms of mood disorders of the caregivers [85]. Suitable mental health education and referral should be provided to the caregiver when indicated.

#### **7.3 Pharmacological interventions**

Although non-pharmacological interventions are preferable because of their minimal, if any, side effects, they do not quickly help patients with sleep problems. Pharmacological interventions have to be considered when sole non-pharmacological interventions do not suffice. Polypharmacy and multiple medical comorbidities are common in older adults and have to be considered when deciding on management plans [24]. Risk-gain balance determines the use of drugs. Fall and cognitive impairments are important considerations for older adults with insomnia treated with drugs. The following provides a brief overview of the general features of common hypnotics on elderly patients. For more details on using of each drug on older people, please view [24].

### *7.3.1 Z-drugs and benzodiazepine*

A meta-analysis that looked into the effect and adverse drug effects of Z-drugs and benzodiazepines suggested that the effects of sedatives may be diminished in elderly people compared with younger adults [90]. The same meta-analysis also concluded that these sedatives were associated with a higher incidence of falls and likeliness of morning or daytime sleepiness among elderly people [90]. These drugs may impair older adults' balance and cognition and subsequently lead to falls [91]. A higher risk of falls and fractures is related to dose, acting time of agents, concurrent using interacting drugs and time from treatment initiation; that is, 1–2 weeks after treatment initiation is associated with a high risk of falls [91]. Evidence also suggests a higher rate of fracture associated with Zolpidem compared with other benzodiazepines [91].

In elderly patients with severe generalised anxiety disorders and RBD, the use of benzodiazepines is more justifiable [92]. Otherwise, the use of benzodiazepines to treat insomnia should be minimised in elderly people due to the increased sensitivity and decreased metabolism in elderly [92]. Apart from the risk of falls and fractures, benzodiazepine may increase the risk of cognitive decline and delirium [92]. There is also a high risk of misuse of benzodiazepines among elderly patients, who are more vulnerable to the serious effects of benzodiazepine misuse [93]. Benzodiazepine should not be routinely used to treat elderly patients with insomnia [24]. Withdrawal and discontinuation of benzodiazepines should always be considered, given the benefits of doing so on the psychical and psychological health of elderly patients [93].

## *7.3.2 Melatonin and Ramelteon*

Melatonin may be considered a safer alternative to benzodiazepines in some patients as melatonin is believed not to cause withdrawal and dependence symptoms [94]. Ramelteon is a melatonin receptor agonist, which has been shown to be effective for older adults with chronic insomnia in different studies, particularly for those with difficulties in falling asleep [24, 95]. There is also evidence suggesting ramelteon may help prevent delirium in medically ill elderly people [96].

### *7.3.3 Other drugs for insomnia*

Some other drugs are used to treat insomnia. Diphenhydramine also provides a sedative effect; however, the possible strong adverse effects in elderly people, including confusion, constipation, dry mouth and cognitive decline in long-term use, suggested that diphenhydramine should not be used for chronic insomnia [24, 92]. Suvorexant is an orexin receptor antagonist that was approved in the USA and Japan for treating insomnia at doses of 10–20 mg [97]. There is evidence suggesting no association between cognitive, psychomotor performance and drug usage at therapeutic dose [98]. Nevertheless, it is still recommended that patients of this drug should take driving precaution and monitoring of apnea-hypopnea index in case of sleep apnea [24].

## *7.3.4 Drugs for mood disorders, dementia and delirium with sleep problems*

Several antidepressants have been used to treat anxiety disorders and depression in elderly patients. Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are the mainstay of treatment for

late-life anxiety disorders, while benzodiazepines are for patients with severe anxiety [86, 92, 99]. Effective SNRIs for treating anxiety disorders in the elderly include venlafaxine, duloxetine, desvenlafaxine, vortioxetine and mirtazapine [99]. Particularly, mirtazapine carries sedating effect and also can increase patients' appetite [84, 99]. Mirtazapine is thought to be a safe option for elderly patients due to its low cardiotoxicity and no significant changes in vital signs when compared with the placebo group [84]. However, compared with younger adults, older adults on mirtazapine may have a higher chance of experiencing dry mouth, constipation and dizziness [84]. In addition to mirtazapine, trazodone and doxepin are also antidepressants that help insomnia. Use of trazodone in the elderly requires particular cautions due to risks of orthostatic hypotension, cardiac arrhythmias, priapism and psychomotor and cognitive impairment [23, 24, 83]. Doxepin, a tricycle antidepressant, can help elderly people with sleep maintenance [23, 24]. It has few adverse effects on memory and cognitive function [24]; however, reduced clearance of the drug in elderly people with low reduced renal functions may lead to prolonged sedation [24].

Some of the drugs mentioned above are also used in AD patients with insomnia, including low-doze trazodone, mirtazapine and melatonin [39]. Drugs with anticholinergic activities, including antihistamines and tricyclic antidepressants, may exacerbate cholinergic abnormalities and should be avoided in treating elderly patients with AD and insomnia [46, 100]. For patients with LBD, hypersomnia in Lewis body dementia can be treated with modafinil, although some researchers may consider the supporting evidence not strong [47]. Insomnia can be treated with low doses of melatonin [47]. Mirtazapine may exacerbate REM sleep behaviour disorder [47]. lBD patients with autonomic dysfunction may experience orthostatic hypotension, and head elevation during sleep may be needed [47].

Antipsychotics are used in demented elderly patients who are psychotic, severely agitated, aggressive and need drug treatment for sleep [39, 46, 100]. However, the use is controversial due to the possible increase in mortality [39]. For patients with LBD, quetiapine or clozapine is preferred due to their sedative and antipsychotic effects [46]. However, some scholars do not support the use of these antipsychotics in LBD, given little supporting evidence and possible adverse effects on the motor and cognitive of patients. Similarly, use of antipsychotics in patients with hyperactive delirium is also controversial. Some scholars deem the evidence supporting the effectiveness of antipsychotics on delirious elderly people weak [70]. For example, olanzapine may reduce incidence but increase the duration and severity of delirium [70]. Pharmacological treatments in hyperactive delirium for pain relief and sleep enhancement using melatonin are, nevertheless, preferable [70].

## **8. Conclusion**

Insomnia is common in elderly people. Identifying underlying psychiatric and medical comorbidities is important for management. Non-pharmacological should always be maximised. Pharmacological treatments are effective, but special cautions are needed to protect elderly people from possible but serious adverse effects, including falls and cognitive decline. Antipsychotics are commonly used in clinical practice for agitated elderly people with dementia and delirium. However, adverse effects may not outweigh the benefits, and limited evidence supports the use of antipsychotics in these patients.

*Common Sleep Problems and Management in Older Adults DOI: http://dx.doi.org/10.5772/intechopen.111656*

## **Conflict of interest**

The authors declare no conflict of interest.

## **Author details**

Pak Wing Cheng\* and Yiu Pan Wong The University of Hong Kong, Hong Kong

\*Address all correspondence to: chengpsy@hku.hk

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## Section 3
