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Steven R. Barczi, M.D. Madison V.A. GRECC Section of Geriatrics/Gerontology University of Wisconsin School of Medicine and Public Health Sleep Disorders.

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Presentation on theme: "Steven R. Barczi, M.D. Madison V.A. GRECC Section of Geriatrics/Gerontology University of Wisconsin School of Medicine and Public Health Sleep Disorders."— Presentation transcript:

1 Steven R. Barczi, M.D. Madison V.A. GRECC Section of Geriatrics/Gerontology University of Wisconsin School of Medicine and Public Health Sleep Disorders in Older Persons Cathy A. Alessi, MD VA Greater Los Angeles GRECC – Sepulveda Campus UCLA Multicampus Program in Geriatric Medicine and Gerontology

2 2 Part One: Age-Related Changes in Sleep and Conditions that Impair Sleep in Older People

3 3 Karacan et al, 1976; Vitiello et al, 2004 Sleep Complaints as We Age Age 50 40 30 20 10 0 Percent 10-19 20-29 30-39 40-49 50-59 60-69 70+

4 4 2003 Sleep in America Poll National Sleep Foundation survey; US adults aged 55 – 84 (N = 1506) Age 55 – 64 Age 75 - 84 Naps 4 – 7 times per week 10%24% Difficulty falling asleep 19%16% Awake a lot during the night 33%35% Daytime sleepiness interferes with daily activities 28%28% www.sleepfoundation.org

5 5 The Consequences of Poor Sleep/ Daytime Sleepiness Decrements in attention, vigilance and memory Dinges DF, ‘97 Decrements in attention, vigilance and memory Dinges DF, ‘97 Increased depression Ford DE, 1989 Increased depression Ford DE, 1989 Increased problems with balance and falls when using sedatives Schorr RI, ‘94; Tinetti M Increased problems with balance and falls when using sedatives Schorr RI, ‘94; Tinetti M Increased MVAs Lyznicki JM 1998 Increased MVAs Lyznicki JM 1998 Increased HTN, CVD morbidity and mortality in those with OSA Newman AB 2000 Increased HTN, CVD morbidity and mortality in those with OSA Newman AB 2000

6 6 The Basic Principles of Sleep Non-REM sleep Non-REM sleep –stage 1- transitional –stage 2- majority of sleep time –stages 3 & 4 - slow wave sleep; restorative REM sleep REM sleep –active EEG, dreams, rapid eye movements, skeletal muscle paralysis, autonomic activation, respiratory instability –related to memory

7 7 Changes in Sleep with Aging The ability to stay asleep changes most markedly with aging Sleep is cyclical

8 8 Modified from: Carskadon MA et al. J Geriatr Psychiatry. 1980;13:135-151; Reprinted from: Ancoli-Israel S. All I Want Is a Good Night’s Sleep. Mosby; 1996 Average Time to Fall Asleep (Minutes) Time of Day 10001200140016001800 20 15 10 5 0 Adolescents Younger Adults Older Adults Sleep Apnea Narcolepsy Sleepiness Across Lifespan

9 9 Medical Illness & Medications Psychiatric & Neurologic Primary Sleep Disorders Circadian Changes Poor Sleep Behaviors Causes of Disturbed Sleep in Aging Poor Sleep Behaviors Circadian Changes Sleep Problem

10 10 Selected Medical Conditions that Disrupt Sleep Pain: arthritis, cancer, neuropathy Cardiac and Vascular: angina, CHF, PVD Pulmonary: COPD, secretions, bronchospasm, Gastrointestinal: GE reflux, ulcer pain, hunger Endocrine: hypo/hyperthyroidism, diabetes Genitourinary: BPH and nocturia, incontinance

11 11 Medications that Influence Sleep & Wakefulness Agents that affect sleep character OTC decongestants OTC decongestants Beta agonist MDI’s Beta agonist MDI’s Caffeine containing OTCs Caffeine containing OTCs Theophylline Theophylline Activating antidepressants Activating antidepressants Selegeline Selegeline Corticosteroids Corticosteroids Beta blockers Beta blockers Acetylcholinesterase Inhibitors Acetylcholinesterase Inhibitors Certain antiarrhythmics Certain antiarrhythmics Agents that cause sleepiness Analgesics (e.g., narcotics) Analgesics (e.g., narcotics) Antidepressants (e.g., imipramine, trazodone) Antidepressants (e.g., imipramine, trazodone) Antihypertensives (e.g., clonidine) Antihypertensives (e.g., clonidine) Antihistamines Antihistamines Antimuscarinics (e.g. Ditropan) Antimuscarinics (e.g. Ditropan) Dopamine Agonists Dopamine Agonists Antiepileptics (e.g. Neurontin) Antiepileptics (e.g. Neurontin) Almost one-third of all prescription medications in PDR list insomnia as a possible side effect

12 12 Psychiatric/ Neurological Causes of Insomnia Depression (sleep maintenance, early am awakenings, short REM latency) Depression (sleep maintenance, early am awakenings, short REM latency) Anxiety/ PTSD (sleep initiation, sleep awakenings, parasomnias) Anxiety/ PTSD (sleep initiation, sleep awakenings, parasomnias) Dementia (sleep wake dysregulation, sleep maintenance, nocturnal wandering) Dementia (sleep wake dysregulation, sleep maintenance, nocturnal wandering) Parkinsonism (sleep maintenance, restless legs, periodic limb movements, REM sleep behavior disorder) Parkinsonism (sleep maintenance, restless legs, periodic limb movements, REM sleep behavior disorder)

13 13 Prevalence of Primary Sleep Disorders Condition All Adults Elderly Sleep Apnea Sleep Apnea 1%-10% 24%-40% Periodic Limb Movements Periodic Limb Movements 5% 30%-45% Restless Leg Syndrome Restless Leg Syndrome 2%-15% 12%-30% REM Sleep BehaviorD/O REM Sleep BehaviorD/O 0.5% 0.5%-2% Young T, et al., Ancoli-Israel S, et al., Sleep 2001; Mant E, et al., Age and Ageing 1992; Ancoli-Israel S, et al. Sleep 1993; Phillips BA, et al., Sleep 1994; Hoch CC, et al., Sleep 1994; O’Keefe ST, et al., Age and Ageing 1994; Phillips B, et al., Arch Int Med 2000; Allen R, et al. Arch Int Med 2005

14 14 Part Two: Clinical approaches to sleep problems including non- pharmacological and pharmacological interventions

15 15 Obstructive Sleep Apnea “typical patient” = obese, sleepy, snorer with hypertension “typical patient” = obese, sleepy, snorer with hypertension exam: obesity, large neck, crowded oropharynx exam: obesity, large neck, crowded oropharynx common symptoms: common symptoms: –poor sleep restoration, excessive daytime sleepiness, –loud crescendo snoring, cessation of breathing, choking sounds during sleep –nocturia, nighttime confusion, morning headache, –poor memory, irritability, personality changes –hypertension, right heart failure, arrhythmias

16 16 High Risk for Sleep Apnea (2 of 3 categories required) Sleepiness Sleepiness –3-4x/week or –asleep while driving Associated conditions Associated conditions –hypertension or –Obesity w BMI >30 kg/m 2 Snoring –louder than speech or –3-4x/week or –bothered others or –observed breathing pauses 3-4x/week Berlin (Cleveland) Sleep Questionnaire- Netzer N, Ann Int Med 1999

17 17 Sleep Apnea Consequences Increased car accidents Increased car accidents Impaired memory Impaired memory High blood pressure High blood pressure Increased stroke risk Increased stroke risk Increased heart rhythm disturbances Increased heart rhythm disturbances Worsened heart failure Worsened heart failure Increased mortality in heart failure Increased mortality in heart failure Ancoli-Israel, et al. Sleep, 1996 Days Cumulative Proportion Surviving Peppard PE, et al. NEJM 2000; Newman AB, et al. Am J Epidemiol 2001; Lanfranchi PA, et al. Circulation 1999; Mallon L, et al. J Intern Med 2002; Yaggi H et al, NEJM; 2005.

18 When to Treat Sleep Apnea in the Elderly? Symptomatic from sleepiness Symptomatic from sleepiness When co-morbid conditions may benefit from treatment When co-morbid conditions may benefit from treatment –Cognitive dysfunction –Congestive Heart Failure –Hypertension –Nocturia When AHI or desaturations are severe When AHI or desaturations are severe

19 19 Treatment of Sleep Apnea Continuous positive airway pressure (nasal CPAP, BiPAP, Auto-CPAP, VPAP) Continuous positive airway pressure (nasal CPAP, BiPAP, Auto-CPAP, VPAP) Oral appliances Oral appliances Surgery Surgery –UPPP or LAUP –Mandibular advancement Other (wt loss, tobacco cessation, supine preclusion, modafinil) Other (wt loss, tobacco cessation, supine preclusion, modafinil) Less favorable outcomes over age 50 Improve QOL, sleepiness and cognition www.sleepapnea.org

20 20 Periodic Limb Movements of Sleep (PLMS) Periodic episodes of repetitive (q 20-40 sec), stereotyped limb movements during sleep (extend big toe, dorsiflex ankle, flex knee) Periodic episodes of repetitive (q 20-40 sec), stereotyped limb movements during sleep (extend big toe, dorsiflex ankle, flex knee) Limb movements may result in arousals, sleep fragmentation and daytime sleepiness Limb movements may result in arousals, sleep fragmentation and daytime sleepiness

21 21 PLMS in Aging in Parkinsonism, renal disease, diabetes and spinal disease in Parkinsonism, renal disease, diabetes and spinal disease Prevalence is higher but severity does not worsen with increasing age Gehrman 2002 Prevalence is higher but severity does not worsen with increasing age Gehrman 2002 Medications can exacerbate problem: TCAs & SSRIs antidepressants, anti- psychotics, Lithium, ETOH Medications can exacerbate problem: TCAs & SSRIs antidepressants, anti- psychotics, Lithium, ETOH

22 22 PLMS Management Modify medications (if possible) Modify medications (if possible) Encourage modest PM exercise Encourage modest PM exercise Dopamine agonists or L-Dopa Dopamine agonists or L-Dopa Gabapentin Gabapentin Benzodiazepines Benzodiazepines Opioids Opioids Second line agents due to adverse effect profiles Not FDA approved for this condition

23 23 Features of Restless Legs Syndrome (RLS) Urge to move extremities associated with paresthesias/ dysesthesias Urge to move extremities associated with paresthesias/ dysesthesias Worsening of symptoms at rest with temporary relief with movement Worsening of symptoms at rest with temporary relief with movement Worsening of symptoms in evening/ at bedtime (circadian component) Worsening of symptoms in evening/ at bedtime (circadian component)www.rls.org

24 24 RLS: Risks and Associated Conditions Family history Family history Medical conditions: Fe deficiency anemia, Renal Insufficiency, Neuropathy (DM, RA) Medical conditions: Fe deficiency anemia, Renal Insufficiency, Neuropathy (DM, RA) Periodic limb movements Periodic limb movements Medications can exacerbate: Caffeine, antihistamines, TCAs, SSRIs, antipsychotics, metoclopramide Medications can exacerbate: Caffeine, antihistamines, TCAs, SSRIs, antipsychotics, metoclopramide NIH Publication #00-3788, 2000

25 25 RLS Management Dopamine agonists> Sinemet Dopamine agonists> Sinemet Opioids Opioids Gabapentin/ Carbamazapine Gabapentin/ Carbamazapine Iron replacement (if ferritin <50mcg)) Iron replacement (if ferritin <50mcg)) ? Clonidine ? Clonidine ? Magnesium ? Magnesium ? Clonazepam/ BZDs (No RCT supports efficacy) ? Clonazepam/ BZDs (No RCT supports efficacy) Allen 2001 Allen 2001 Efficacy supported by RCTs (OFF LABEL USE except Ropinirole )

26 26 REM Sleep Behavior Disorder major features: major features: –vigorous motor behaviors and vivid dreams –lack of muscle atonia during REM sleep= “acting out dreams” –may result in injury; > 85% of cases are men etiology (males>> females) etiology (males>> females) –acute: drug-induced (e.g., SSRIs, TCAs) and drug withdrawal –chronic: idiopathic, synucleinopathies (e.g., Parkinson’s disease, Lewy body dementia, multi-system atrophy), psychiatric illness diagnosis: polysomnography diagnosis: polysomnography treatment treatment –environmental safety –Melatonin or donepazil if cognitive impairment, neurodegenerative –alternatives: clonazepam or temazepam

27 27 Insomnia is a symptom as much as a diagnosis (one needs to seek out the cause)

28 28 Evaluation of Sleep Problems Interview Interview Sleep log, sleep questionnaires Sleep log, sleep questionnaires Focused physical exam & laboratory testing Focused physical exam & laboratory testing Indications for polysomnography*: Indications for polysomnography*: –When sleep-related breathing disorder or periodic limb movement disorder is suspected –When initial diagnosis is uncertain, treatment fails (behavioral or pharmacologic), or precipitous arousals occur with violent or injurious behavior Littner et al. American Academy of Sleep Medicine. Standards of Practice Committee. Sleep 26(6):754-760, 2003.

29 29 The Sleep Interview Is there a complaint of poor sleep or unsatisfactory sleep? (daytime consequences?) Is there a complaint of excessive daytime sleepiness? Sleep Schedule and Napping Snoring, apneas, abnormal movements Alcohol / caffeine use Amount and timing of daily light exposure Daily exercise Sateai et al. Evaluation of Chronic Insomnia. SLEEP. 23(2):243-308, 2000.

30 30 Treatment Options for Later Life Insomnia Behavioral Approaches (CBT) Behavioral Approaches (CBT) –Stimulus control, sleep restriction, relaxation, cognitive restructuring Bright Light Therapy Bright Light Therapy Sedative-Hypnotics Sedative-Hypnotics Sedating Antidepressants Sedating Antidepressants

31 31 Cognitive-Behavioral Therapy Nine randomized controlled trials support efficacy of cognitive-behavioral therapy (CBT) for improved sleep maintenance in older adults Nine randomized controlled trials support efficacy of cognitive-behavioral therapy (CBT) for improved sleep maintenance in older adults 2 RCTs support that patients with chronic insomnia have more sustained improvement when receiving CBT (compared to drug tx) Morin 1999, Sivertsen 2006 2 RCTs support that patients with chronic insomnia have more sustained improvement when receiving CBT (compared to drug tx) Morin 1999, Sivertsen 2006

32 32 Common non-pharmacological measures to improve sleep regular bedtime/ rising time regular bedtime/ rising time go to bed only when sleepy go to bed only when sleepy get out of bed if unable to fall asleep get out of bed if unable to fall asleep decrease/eliminate daytime naps decrease/eliminate daytime naps exercise (am, afternoon) exercise (am, afternoon) use bed only for sleeping use bed only for sleeping eliminate alcohol/ tobacco before bedtime eliminate alcohol/ tobacco before bedtime wind down, relax wind down, relax control environment, follow bedtime ritual control environment, follow bedtime ritual

33 33 RCT: CBT vs. Pharmacotherapy for Insomnia in Older Adults Morin C et al. JAMA 1999; 281:11 PCT was Temazepam

34 34 Hypnotic Use in Older Adults 32% of adults 65 yrs and older have taken medications to aid sleep in past yr NSF 2000 32% of adults 65 yrs and older have taken medications to aid sleep in past yr NSF 2000 Adults over age 65 comprise 13% of the population but use 40% of all sedative- hypnotics prescribed. Mellinger 1985 Adults over age 65 comprise 13% of the population but use 40% of all sedative- hypnotics prescribed. Mellinger 1985 National Sleep Foundation Poll 2003 Roehrs 1989 Beers 1988

35 35 Psychotropic Use: Hip Fracture Cases vs. Age and Gender-Matched Controls Glynn, 2001

36 36 Medications Approved by the FDA for Insomnia Medication Duration of Action ½ life Dose Benzodiazepines Triazolam (Halcion) Short 2-5 hrs 0.125-0.25mg Temazepam (Restoril) Intermediate 8-15 hrs 7.5-30mg Estazolam (ProSom) Intermediate 10-24 hrs 0.5-2 mg BZD Receptor Agonists Zaleplon (Sonata) Ultra-short 1 hr 5-20 mg Zolpidem (Ambien Short 1.5-4.5 hrs 5-10 mg Zolpidem CR (Ambien CR) Short-Intermed 1.5-4.5 hrs 6.25-12.5 mg Eszopiclone (Lunesta) Intermediate 6-9 hrs 1-3 mg Melatonin Receptor Agonist Ramelteon (Rozerem) Short 2-5 hrs 8mg

37 37 Hypnotics Trials in the Elderly StudyDrug Type/ Duration Efficacy Geriatric Outcomes Nakra ’92 N=45 TemazepamTriazolam DB /single dose Subjective; + sleep latency Neuro-psych: dec learning Shaw ’92 N=119 Zolpidem DB placebo cont/ 21 days Subjective; inc TST None measured Roger ’93 N=221 TriazolamZolpidem DB placebo cont/ 21 days Subjective; inc sleep quality Dec memory triazolam> zolp Vgontzas ’94 N=8 Temazepam DB placebo cont/ 7 days Subj; inc sleep time “no memory changes” Hedner ’00 Zaleplon RCT/ 14 days Subj + sleep latency, + TST NC – cognition No falls data Unpublished ’03 N=292, N=231 Eszopiclone RCT/ 2 wks; 2 wks Subj + sleep quality, +TST NC- cognition, no falls NC- cognition, no falls DB= double blind, RCT= randomized controlled trial, TST= total sleep time

38 38 Pharmacologic Approaches – Agents to Avoid Based upon Geriatrics Literature, side effect profiles exceed benefit with: –Antihistamines –Barbiturates –Long half-life benzodiazepines –High-anticholinergic tricyclic antidepressants

39 39 Pharmacologic Approaches - Antidepressants The role for these agents in non-depressed agents is actively debated (This is OFF LABEL USE) The role for these agents in non-depressed agents is actively debated (This is OFF LABEL USE) Trazodone- most widely prescribed hypnotic (used for dementia) but limited efficacy data, orthostasis & rebound insomnia Trazodone- most widely prescribed hypnotic (used for dementia) but limited efficacy data, orthostasis & rebound insomnia Mirtazapine is sedating but data regarding long term adverse effects and efficacy is absent Mirtazapine is sedating but data regarding long term adverse effects and efficacy is absent

40 40 Part Three: Sleep in Institutional Settings: the Hospital and the Nursing Home

41 41 Insomnia in Hospitalized Patients Very little literature focuses on management of insomnia in hospitalized adults… Factors associated with sleep changes include: –Acute physical symptoms (e.g. pain, dypnea) –Psychological response (anxiety, depression) –Shift in sleep-wake cycle due to environment –Sustained bed rest/ daytime napping –Delirium

42 42 In Hospital Causes for Awakenings (N=52, 24 women, mean age= 57.4) Nocturia 73% Nocturia 73% Noise 48% Noise 48% (RN-RN and RN-patient conversations, machinery) RN checks/ observation40% RN checks/ observation40% Medication passes40% Medication passes40% Pain or discomfort 30% Pain or discomfort 30% Lights 27% Lights 27% (RN station, corridors, flashlights) Jarman et al., Int J Nursing Prac 8:75-80, 2002

43 43 Noise in Hospital Cmiel et al., Am J Nursing 2004 104:40-48 Hospital Sounds Comparable Sounds Loudest transient at change of shift – 113 dB Jackhammer – 111 dB Portable X-ray machine – 98 dB Motorcycle – 95 dB Bedside monitor alarms – 75 dB Heavy truck traffic – 81 dB Empty semiprivate room – 53 dB Conversational speech – 60 dB EPA-recommended average noise level for hospital in daytime = 45 dB; nighttime average = 35dB

44 44 RN Sleep Promotion Team- Noise Reduction Cmiel et al., Am J Nursing 2004 104:40-48 Pre-interventionPost-intervention Shift change peak 113 dB Shift change peak 86 dB Staff Interventions- report in designated rooms, close patient doors, cover IV pump speakers, change time of supply staff deliveries, avoid housekeeping staff shortcuts, eliminate unit overhead pages between 9pm-7am; reschedule non-urgent X-ray and lab times Equipment interventions- adjust cardiac monitor alarm volumes, padded pneumatic tube receptacles, alter paper towel dispensers

45 45 A Non-pharmacologic Sleep Protocol in an Acute Hospital Setting (McDowell et al., JAGS 1998, 46(6):700-705) Prospective Cohort of 111 patients, mean age 79.3 (± 6.4), 68% women Intervention: warm drink, relaxation tapes and back massage at HS; option for hypnotic therapy (HT) if ineffective Outcomes: Absolute reduction of 23% for HT use from pre- to post intervention Absolute reduction of 23% for HT use from pre- to post intervention Overall adherence rate was 400/539 (74%) patient-days Overall adherence rate was 400/539 (74%) patient-days The sleep protocol had a stronger association with quality of sleep (rho =.75, P =.001) than did HT (rho =.07, P =.45) The sleep protocol had a stronger association with quality of sleep (rho =.75, P =.001) than did HT (rho =.07, P =.45)

46 46 Many factors contribute to sleep problems in NH residents Age-related changes in sleep Age-related changes in sleep Dementia, depression Dementia, depression Other illnesses Other illnesses Medications (including sedatives) Medications (including sedatives) Increased prevalence of sleep disorders (e.g., sleep apnea) Increased prevalence of sleep disorders (e.g., sleep apnea) Poor sleep hygiene, lack of bright light exposure Poor sleep hygiene, lack of bright light exposure Sleep-disruptive NH environment and routines Sleep-disruptive NH environment and routines

47 47 Benzodiazepines increase the risk of falls in NH residents (Ray et al. JAGS 48:682-685, 2000) (N = 2510 residents in 53 Tennessee NHs) Daytime falls (7 am – 8 pm) Nighttime falls (8 pm – 7 am) Any benzodiazepine 1.38 (1.25-1.51) 1.83 (1.55-2.15) Short-acting* (half-life< 12 hours) NS 2.19 (1.59-3.03) Intermediate- acting (half-life 12-23 hrs) 1.43 (1.29-1.59) 1.68 (1.39-2.02) Long-acting (half-life > 24 hrs) 1.77 (1.38-2.26) 1.80 (1.14-2.83) *Includes temazepam, oxazepam, zolpidem, triazolam Rate ratios (95% confidence intervals); adjusted for age, gender, race, time since admission to facility and since zero time, BMI, ambulatory status, ADL dependency, incontinence, cognitive impairment, physical restraint use, past falls, and use of anticonvulsants, antiparkinsonian drugs, antidepressants, antipsychotics, and other sedatives. Reference group is non-users, no benzos in preceding 7 days.

48 48 Effects of light treatment on sleep and circadian rhythms in demented NH residents (Ancoli-Israel et al. JAGS 50:282-289, 2002) RCT, N = 77 demented residents in 2 NHs RCT, N = 77 demented residents in 2 NHs Treatment groups (10 day treatment) : Treatment groups (10 day treatment) : –Evening bright light (2500 lux 5:30 pm – 7:30 pm) –Morning bright light (2500 lux 9:30 am – 11:30 am) –Daytime sleep restriction (attended to 6 hrs each day by research staff to restrict daytime sleeping) –Evening dim red light (<50 lux 5:30 pm – 7:30 pm) Wrist actigraphy outcomes: Wrist actigraphy outcomes: –No effects on nighttime sleep or daytime alertness. –Significant effects on circadian rhythms of activity

49 49 Daily social and physical activity intervention: effects on sleep and memory (Naylor et al. Sleep 23:87-95, 2000) Controlled trial, N = 23 residents in a continued care retirement facility Controlled trial, N = 23 residents in a continued care retirement facility Intervention: Intervention: –Enforced schedule of structured social and physical activity (9 – 10:30 am, 7 pm – 8:30 pm; daily for two weeks) Results: Results: –Increased slow wave sleep (by polysomnography) –Improvement in memory-oriented tasks (by neuropsychological testing)

50 50 RCT of a nonpharmacological intervention to improve sleep in NH residents (N=118 residents from 4 NHs) Alessi et al, JAGS 53:803-810, 2005 Intervention combined efforts to: Intervention combined efforts to: – ↓ daytime in-bed time – ↑ daytime sunlight exposure – ↑ daytime physical activity – ↓ nighttime noise and light –provide bedtime routine Results: Results: –Modest decrease in duration of nighttime awakenings –Nearly 50% decrease in daytime sleeping –Increased participation in social and physical activities and social conversation

51 51 Summary: Sleep Changes in Older Adults Complex interplay of multiple factors (rarely does one factor cause changes) Complex interplay of multiple factors (rarely does one factor cause changes) Medical and psychological factors play increasing role in later life Medical and psychological factors play increasing role in later life Primary sleep disorders are more prevalent in older persons Primary sleep disorders are more prevalent in older persons Improving sleep behavioral factors and treating illness is first step Improving sleep behavioral factors and treating illness is first step Risks for hypnotic use increase with age Risks for hypnotic use increase with age Poor Sleep Behavior Medical Illness & Medications Psychiatric and Neurologic Primary Sleep Disorders Circadian Changes Sleep Problem


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