A 72-year-old man comes to the office due to poor sleep. He is concerned that he is sleeping less since he retired a year ago. He says, "I used to sleep a solid 8 hours, but now I wake up several times a night. And I'm up for the day between 5:00 and 6:00 AM, which is a full hour before I want to get up. I'm probably only getting about 6 or 7 hours of sleep total." The patient typically falls asleep while watching television at 10:00 PM. He sometimes awakens to use the bathroom in the middle of the night but typically falls back asleep within 15 minutes. The patient likes to do crosswords and play golf in the mornings but occasionally takes 30-minute naps in the afternoon. The patient's wife says that he snores softly, but she has not witnessed any breathing pauses. Medical problems include hypertension and a history of depression. The patient does not use alcohol or illicit drugs. Which of the following is the most likely cause of this patient's symptoms?
This patient's sleep changes are consistent with normal aging. Age-related changes in sleep architecture include decreased total sleep time and slow-wave sleep with increased nighttime sleep latency. As a result of these changes, elderly patients may experience more fragmented sleep with nocturnal awakenings and an earlier wake-up time when compared to their previous sleep pattern. All these changes can in turn lead to subjective reports of insomnia and intentional and unintentional daytime napping.
This patient functions well during the daytime and does not exhibit any other symptoms that would be concerning for a sleep disorder (eg, sleep apnea). He should be reassured that these changes are normal.
(Choice A) Adjustment disorder should be considered in a patient who develops mood symptoms within 3 months of a stressor. If mood symptoms persist for >6 months after the stressor, then adjustment disorder cannot be diagnosed. This patient does not have any mood symptoms, and his retirement was >6 months ago.
(Choice C) Insomnia disorder involves persistent difficulties initiating or maintaining sleep, resulting in clinically significant distress or impairment. It would not be diagnosed in a patient with normal age-related sleep changes.
(Choice D) Although sleep changes are frequent in major depressive disorder, this patient lacks other key depressive symptoms necessary to meet criteria for it (eg, sadness, decreased interest, anhedonia, decreased appetite, suicidality).
(Choice E) Sleep apnea is associated with hypertension and fragmented sleep. However, this patient has no history of witnessed apneas and his sleep changes are classic for normal aging.
(Choice F) REM sleep behavior disorder is a parasomnia characterized by dream-enactment behaviors that occur due to loss of normal REM sleep atonia.
Educational objective:
Age-related sleep changes may be reported as insomnia and must be differentiated from primary sleep disorders and other disorders. Normal changes include decreased total sleep time, increased nighttime awakenings, sleepiness earlier in the evening with earlier morning awakening, and increased daytime napping.