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Introduction
Sleep disturbances including insomnia are some of the most common complaints of older people and can significantly impact on quality of life. Despite this, they are rarely specifically asked about at encounters with health professionals. This may reflect either a trivialization of their significance or conflicting messages about optimum management. It is relatively easy to immediately prescribe a hypnosedative such as a benzodiazepine (BZD), yet the published literature is often critical of such an approach. Insomnia and sleep disturbances are not benign - they are associated with a range of morbidities, and even excess mortality, although this is difficult to separate from the effects of both the underlying causes and of hypnosedative therapy. Even less well known is whether the effective treatment of insomnia reduces these potential consequences. The management of sleep disturbances in older people can be particularly challenging in certain situations, including for those with dementia, depression and in residential care.
This is an evolving field, although there have been few recent major 'breakthroughs' in our understanding and management. Certainly, the better understanding of rapid eye movement sleep behaviour disorders and the newer hypnosedatives including melatonin-related therapies are advances, but we are a long way from eliminating sleep disturbances in older people.
This review is based on a search of recent published literature using the terms 'sleep', 'older', 'aged', 'insomnia', 'benzodiazepine' and 'hypnosedatives' along with key older research articles and reviews in the author's literature collection. The Australian National Presenting Service (NPS) has recently targeted insomnia and hypnosedative use in older people and provided a comprehensive literature search that was also used in this review.
Sleep changes with ageing
Sleep consists of two distinct states (Figure 1) - rapid eye movement (REM) and non-REM (NREM). During the latter, neurological repair and restoration of physiological systems occur. NREM sleep can be divided into four further stages. Stage 1 is a transitional stage from awake to asleep, whereas stage 2 is the onset of sleep and constitutes the larger proportion of sleep time (around 50%). During stage 2, the EEG shows rapid 'alpha' waves. People can be easily aroused from stage 1 and 2 sleep and some interpret these stages as not being truly asleep. Stages 3 and...