INTRODUCTION — Sleep-related complaints are common among older adults (ie, adults >65 years old). In older adults, it is often difficult to distinguish whether such complaints are a consequence of normal aging, a primary sleep disorder, or a medical illness [1-3].
The causes of impaired sleep in older adults are reviewed here, with a focus on sleep apnea. The diagnosis of sleep apnea in adults is discussed elsewhere. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "Management of obstructive sleep apnea in adults" and "Central sleep apnea: Risk factors, clinical presentation, and diagnosis" and "Central sleep apnea: Treatment".)
EVALUATING SLEEPINESS IN OLDER ADULTS — When evaluating sleep in older adults, we determine whether the patient’s symptoms are consistent with the following:
●Normal aging (see 'The normal effects of aging on sleep' below)
●A primary sleep condition (see 'Common primary sleep disorders in older adults' below)
●Other issues of sleep impairment common in the older adult (eg, poor sleep hygiene, medication effect, or a medical illness) (see 'Sleep hygiene, medications, and comorbidity issues' below)
Evaluation — We encourage all clinicians to evaluate older adults with a thorough history and examination in order to elucidate sleep complaints and habits. The threshold to inquire about sleep should be particularly low in those with risk factors for sleep disorders. This includes patients with heart failure and stroke (ie, risk factors for sleep apnea), a recent psychologically traumatic event (eg, death of a family member; risk factor for insomnia), dementia, depression, and anxiety (ie, risk factors for insomnia), Parkinson’s disease (ie, risk factor for rapid eye movement sleep behavior disorder), and anemia and renal failure (ie, risk factors for restless leg syndrome).
We question patients and their bed partner (if available) regarding their typical sleep habits. At a minimum this should include their usual bedtime, how long it takes to fall asleep, number of nocturnal awakenings, typical wake time and out of bed time in the morning, snoring, and daytime sleepiness. A sleep log may be useful (table 1 and table 2). We also inquire about medications, caffeine and alcohol intake, or other drug or medication consumption, all of which can affect sleep. Key questions in the evaluation of a sleepy patient (table 3) and a detailed approach to a patient with excessive daytime sleepiness (EDS) are provided separately. (See "Approach to the patient with excessive daytime sleepiness" and "Excessive daytime sleepiness due to medical disorders and medications".)
A propensity for daytime napping (eg, falling asleep in a chair late evening) should not be confused with EDS, which is not normal in the healthy older adult. EDS is defined as inability to maintain wakefulness and alertness during the major waking episodes of the day, with sleep occurring unintentionally or at inappropriate times almost daily for at least three months (eg, falling asleep while talking with someone, in church, in the theater, getting dressed, eating a meal, going to the bathroom). Although not validated in older adults, the Epworth sleepiness scale (calculator 1) may be helpful in this distinction with a score above 10 suggesting primary sleep pathology rather than normal aging effects on sleep. (See "Approach to the patient with excessive daytime sleepiness".)
Testing
Mild symptoms or symptoms consistent with normal aging — We do not typically order sleep testing patients whose complaints are mild and/or consistent with normal aging. We counsel such patients in good sleep habits and monitor for progression of their symptoms.
Symptoms disproportionate with normal aging or consistent with a sleep disorder — If the complaints seem out of proportion to normal aging (ie, are affecting basic activities of daily living or cognitive functioning) or there are other symptoms or signs of a primary sleep disorder, we perform diagnostic testing for coexisting sleep disorders that require treatment. For example, we generally order sleep testing in patients who report getting a reasonable amount of sleep (probably seven hours or more) but have trouble staying awake and need to nap during the day (ie, patients with EDS).
Given the number of medical problems that can cause sleepiness and/or sleep disruption, we perform some basic laboratory tests including complete blood count, routine chemistries, and thyroid function tests.
If not revealing, we generally perform a sleep study (in-home or in-laboratory test). Selecting a home or in-laboratory sleep study is discussed separately. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Selecting home or in-laboratory testing'.)
Others
●History of stroke or transient ischemic attack – We believe that patients with history of stroke or transient ischemic attack should be evaluated for any signs of sleep disordered breathing, and have a low threshold for sleep testing as the prevalence is very high in this population. In these patients, we prefer in-laboratory attended sleep testing since home testing is not likely to be adequate. Sleep apnea is both a risk factor for stroke (approximately two-fold increased incidence) as well as highly prevalent after stroke [4].
●Early dementia – Similarly, we evaluate patients with early dementia for an underlying sleep disorder and have a low threshold to perform in-laboratory or home sleep apnea testing in those with any symptoms suggestive of a sleep disorder (eg, snoring or daytime sleepiness). The rationale for this approach is based upon the observation that sleep symptoms can be difficult to assess in this population and evidence suggests improvement or delayed decline when sleep apnea is treated.
THE NORMAL EFFECTS OF AGING ON SLEEP — Sleep-related changes as a normal consequence of aging are listed in the table (table 4) [2,5-8]. The overall effect of these changes is that many older adults tend to go to sleep and get up earlier (advanced phase syndrome), and complain of difficulty maintaining sleep (due to increased nocturnal awakenings), more so than difficulty initiating sleep. For others, the lack of a fixed schedule (eg, from retirement) can affect sleep hygiene and may even lead to problems with a delayed sleep phase disorder (ie, they can become "night owls"). With age, as the time spent asleep at night decreases, there is increased daytime sleepiness, difficulty maintaining wakefulness, and a propensity for daytime napping. The stages and architecture of normal sleep are described separately. (See "Stages and architecture of normal sleep".)
COMMON PRIMARY SLEEP DISORDERS IN OLDER ADULTS — Common sleep disorders in the older adult include the following:
●Sleep apnea – Obstructive and, less commonly, central sleep apnea are the most common disorders of sleep in later life [9,10] (see 'Sleep apnea' below)
●Insomnia – Insomnia increases in prevalence in later life (see "Evaluation and diagnosis of insomnia in adults")
Other sleep disorders that can be seen but are less common in later life include the following:
●Circadian rhythm sleep disorder (see "Overview of circadian sleep-wake rhythm disorders" and "Delayed sleep-wake phase disorder")
●Rapid eye movement (REM) behavior disorder (see "Rapid eye movement sleep behavior disorder")
●Restless leg syndrome and periodic limb movement disorder (see "Clinical features and diagnosis of restless legs syndrome and periodic limb movement disorder in adults")
Sleep apnea — Sleep apnea is a disorder characterized by apneas and hypopneas during sleep. It collectively describes both obstructive sleep apnea (OSA; in which apneas and hypopneas are due to repetitive collapse of the upper airway) and central sleep apnea (CSA; in which apneas and hypopneas occur in the absence of upper airway collapse). OSA is more common than CSA in all age groups. Herein, we use the term, sleep apnea, when describing OSA and CSA collectively or when describing studies that did not distinguish the type of sleep apnea. Otherwise, we refer to OSA or CSA specifically.
Issues pertinent to sleep apnea in the older adult are discussed in this section while general issues that are common to all patients with sleep apnea, including pathogenesis, diagnosis, and treatment are discussed separately. (See "Pathophysiology of upper airway obstruction in obstructive sleep apnea in adults" and "Central sleep apnea: Pathogenesis" and "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "Central sleep apnea: Risk factors, clinical presentation, and diagnosis" and "Central sleep apnea: Treatment".)
Incidence — The incidence of sleep apnea appears to increase among older individuals [11-14], particularly less healthy older individuals [15]:
●In one study, the prevalence of sleep apnea was 1.7-fold higher in older adults (>60 years) compared with 40- to 60-year-old adults, using an apnea-hypopnea index (AHI) cutoff of ≥15 [16]. (See "Polysomnography in the evaluation of sleep-disordered breathing in adults", section on 'Measures of sleep-disordered breathing severity'.)
●In another observational study that used an apnea index (AI) ≥10 events per hour of sleep to define sleep apnea, the prevalence of sleep apnea was 10 percent among independently living older adults, 21 percent among medical ward patients, and 26 percent among nursing home patients [15]. However, since patients were those referred to a sleep specialist center, the applicability of these results to the general population is uncertain.
Many medical and psychiatric illnesses that are common in older adults are also associated with sleep disordered breathing, typically sleep apnea [17]. Examples include cardiovascular disease such as heart failure (CSA) and chronic obstructive pulmonary disease (OSA). (See "Sleep-disordered breathing in heart failure" and "Sleep-related breathing disorders in COPD".)
In addition, older adults tend to be more sensitive to the effects of sedatives and alcohol due to age-related changes in pharmacokinetics and pharmacodynamics which, in turn, may worsen underlying obstructive sleep apnea.
Natural history — Data describing the natural history of untreated sleep apnea in older adults is weak. Nonetheless, untreated sleep apnea in older adults appears to be associated with an increased risk of stroke, cognitive abnormalities, and heart failure. Unlike younger adults, there is no robust evidence to support an increased risk of death, hypertension, or coronary artery disease. This may be because data in older adults are largely derived from subgroup analyses of studies that included adults of all ages, and the event size may not be large enough to make firm conclusions.
●Stroke – Untreated severe sleep apnea has been associated with increased risk for an ischemic stroke in older adults. In a prospective cohort study of 400 adults aged 70 to 100 years who were followed for six years, an ischemic stroke occurred in 5 percent [18]. Patients with untreated severe sleep apnea (defined as AHI ≥30 events per hour of sleep) had an increased risk of developing an ischemic stroke compared with those who did not have sleep apnea (adjusted hazard ratio 2.52, 95% CI 1.04-6.01).
In a prospective observational study of patients 65 years or older who were suspected as having sleep apnea, incident stroke was significantly more common in patients with AHI ≥15 who were not treated with continuous positive airway pressure (CPAP) [19]. Patients treated with CPAP had the same incidence as those without sleep apnea.
●Cognitive abnormalities – Numerous observational studies have found an association between sleep apnea and cognitive defects [20-23]. In one study, 298 women (mean age of 82 years) underwent polysomnography and were then followed prospectively for four years for the development of neurocognitive defects, as determined by cognitive testing [23]. Women with sleep apnea (defined as AHI ≥15 events per hour of sleep) were more likely to develop mild cognitive defects or dementia than women without sleep apnea (45 versus 31 percent, adjusted odds ratio 1.85, 95% CI 1.11-3.08). A subsequent study of patients with mild cognitive impairment (MCI) or Alzheimer’s disease showed that those with sleep disordered breathing had an earlier age of onset of MCI [24].
●Heart failure – It is unclear whether untreated severe sleep apnea (defined as AHI ≥30 events per hour of sleep) may also be associated with the development of heart failure in older patients. In a prospective cohort study of 4422 adults, both men older and younger than 70 years with severe untreated sleep apnea exhibited a trend toward a higher rate of heart failure than men of the same age who did not have sleep apnea (adjusted hazard ratio 1.58, 95% CI 0.93-2.66) [25].
●Hypertension – In older adults, it is unclear if untreated sleep apnea is associated with an increased risk of hypertension. In one study, untreated sleep apnea was associated with an increased risk of systemic hypertension in patients >65 years old compared with patients <65 years old (adjusted odds ratio 1.44, 95% CI 1.03-2.00) [26]. However, sleep apnea was defined by an oxyhemoglobin saturation <90 percent for ≥12 percent of the sleep time and not by the AHI. In addition, studies that have used the AHI alone to compare older adults with untreated severe sleep apnea to adults without sleep apnea, have found that the strength of the association between sleep apnea and systemic hypertension diminishes with age [26-28].
●Mortality – The increased mortality that is seen in younger adults with untreated sleep apnea has not been seen in older patients, [29-31]. As an example, in a prospective cohort study that followed 6441 adults for an average of eight years, unlike younger adults, untreated severe sleep apnea (defined as AHI ≥30 events per hour of sleep) was not associated with increased mortality in the subgroup of 110 adults who were >70 years old [29]. However, there were too few events in the subgroup to definitively exclude or confirm a true mortality effect.
●Coronary artery disease – In a prospective cohort study that followed 4422 adults for almost nine years, untreated severe sleep apnea (defined as AHI ≥30 events per hour of sleep) was not associated with an increased risk of coronary artery disease (defined as myocardial infarction, revascularization procedure, or death due to coronary artery disease) in older men or in women [25]. Other studies have been unable to replicate these data because there were too few events to allow stratification by age [29].
Clinical manifestations and diagnosis — Evidence indicates that sleep apnea manifests the same way in older and younger adults [32]. However, cognitive deficits and nocturia may be more frequent presentations of sleep apnea in older adults, and both may be reversible with treatment of sleep apnea. Evaluating for OSA following stroke may be another avenue for diagnostic evaluation of OSA in older adults.
The symptoms, signs, and diagnostic investigation of sleep apnea are described in greater detail separately. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "Central sleep apnea: Risk factors, clinical presentation, and diagnosis".)
Treatment — We manage older adult patients with sleep apnea in a similar fashion to younger adults. This includes the indications for treatment, behavior modification, selection of the sleep apnea-specific therapy (ie, positive airway pressure [PAP], oral appliance, surgery), and follow-up. (See "Management of obstructive sleep apnea in adults" and "Central sleep apnea: Treatment".)
However, older adults tend to be more challenging to treat than younger patients for several reasons:
●They experience nocturnal awakenings by virtue of age alone that may not be treated with CPAP.
●Those being managed with PAP therapy may have difficulty achieving a good fit with either a nasal or face mask, especially if they are edentulous. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea" and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Choosing the correct patient-device interface'.)
●Additional time is often needed to educate patients about PAP therapy as well as device use and maintenance. (See "Assessing and managing nonadherence with continuous positive airway pressure (CPAP) for adults with obstructive sleep apnea".)
●Oral appliances may not be an option for some patients because adequate dentition is required to anchor the device in position. (See "Oral appliances in the treatment of obstructive sleep apnea in adults".)
●Comorbidities may prohibit a surgical approach in some patients. (See "Surgical treatment of obstructive sleep apnea in adults".)
Positive airway pressure — PAP therapy is the mainstay of therapy in older adults, although supporting data are more limited than in younger adults (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea".)
●Sleepiness and quality of life – Several studies have examined sleepiness and quality of life in older adults [33-35].
In a multicenter trial that included 278 adults ≥65 years of age with newly diagnosed OSA, patients randomized to receive CPAP therapy plus best supportive care had improved daytime sleepiness compared with those assigned to best supportive care alone [33]. The benefits of CPAP were present at both 3 and 12 months and were greater in those with higher CPAP usage and higher baseline Epworth sleepiness scale scores (calculator 1). Quality of life was no different between the groups. Although the self-reported CPAP adherence rate was relatively high (86 percent at 3 months and 71 percent at 12 months), the median nightly CPAP usage was only two hours, which might have limited efficacy. Other important limitations of the trial include the lack of a sham CPAP control group, allowing for a placebo effect, and the fact that trial entry was based on overnight oximetry parameters rather than polysomnography.
A second randomized clinical trial of 143 patients age 70 or above with an AHI between 15 and 30 showed improvement in Epworth sleepiness scores (calculator 1) and some quality of life measures with three months of CPAP treatment compared with control patients [34].
Whether this benefit is maintained is unclear [36].
●Cognitive function – One randomized trial of 33 patients with OSA who had cognitive dysfunction and a median age of 71 years reported improved short-term and working memory, selective attention, and executive function with CPAP therapy compared with conservative therapy [37]. Another randomized trial in patients with mild cognitive impairment (MCI) reported that while CPAP did not change processing speed or executive functioning, it did improve verbal learning and memory retention compared with no treatment [38]. In contrast, another randomized trial showed no effect of CPAP on cognitive function in patients over 65 years despite improved sleepiness [33]. However, patients in that trial had normal cognitive function at baseline and poor adherence. One meta-analysis of 14 trials reported that CPAP treatment can partially improve cognitive impairment in patients with severe OSA, although the mean age of patients in this analysis was 57 years [39]. A subsequent study of patients with MCI or Alzheimer's disease showed that CPAP may delay the progression of cognitive impairment [24].
●Cardiovascular events and stroke – In a randomized trial of 278 adults ≥65 years of age with OSA, cardiovascular events were similar between patients treated with CPAP and those treated with supportive care [33].
●Mortality – Although mortality has not been definitively shown to be increased in older patients with untreated sleep apnea, one study of more than 25,000 patients with sleep apnea reported that CPAP improved survival in males but not in females ≥60 years of age [40].
Others — Alternatives to PAP therapy are similar to those in younger adults and include oral devices, upper airway surgery (eg, uvulopalatoplasty, tongue reduction, mandibular advancement), and hypoglossal nerve stimulation. (See "Management of obstructive sleep apnea in adults".)
Efficacy data on these options in older adults are rare. Generally, older adults are poor candidates for elective surgery, although a review of data from the ADHERE registry reported a reduction in the AHI compared with baseline in patients over age 65 years who were treated with hypoglossal nerve stimulation [41]. In addition, patient satisfaction with this treatment was actually higher than in younger patients, with no difference in the complication rate. (See "Surgical treatment of obstructive sleep apnea in adults", section on 'Global upper airway procedures'.)
Insomnia — Insomnia may occur in association with comorbid conditions that are common in later life such as chronic pain from arthritis, nocturia from prostatic hypertrophy, psychiatric conditions (eg, dementia, depression, and anxiety), night sweats from menopause, or traumatic events (eg, loss of a loved one). Evaluation and treatment of insomnia in older adults is similar to younger adults with a stronger emphasis on cognitive behavioral therapy. These issues are discussed separately. (See "Evaluation and diagnosis of insomnia in adults" and "Overview of the treatment of insomnia in adults", section on 'Older adults'.)
Other sleep disorders — The evaluation and management of the following sleep disorders that can occur in later life are largely discussed separately and include:
●Circadian rhythm sleep disorder – Most commonly, this can occur when the advanced sleep phase is severe (ie, being awake at night and sleepy during the day). However, older patients are also less likely to have a required fixed schedule, which can lead to worsened sleep hygiene, including irregular or even delayed sleep. (See "Overview of circadian sleep-wake rhythm disorders" and "Delayed sleep-wake phase disorder" and "Sleep-wake disturbances and sleep disorders in patients with dementia".)
●REM behavior disorder – This is rare in the general population but may be seen in males, older adults with dementia, Parkinson's disease, and multiple system atrophy. (See "Rapid eye movement sleep behavior disorder".)
●Restless legs syndrome and periodic limb movement disorder – Anemia and chronic renal failure, which are common in older adults, are risk factors for restless legs syndrome and periodic leg movements of sleep, resulting in poor sleep maintenance [42,43]. (See "Clinical features and diagnosis of restless legs syndrome and periodic limb movement disorder in adults".)
SLEEP HYGIENE, MEDICATIONS, AND COMORBIDITY ISSUES — In patients where poor sleep habits, medications, or comorbidities explain or contribute to sleep-related complaints, the underlying issues should be addressed.
●Poor sleep hygiene – Poor sleep habits may contribute to sleep complaints in older adults. Examples include spending long periods of time in bed, having an irregular sleep schedule, trying to force sleep, drinking caffeinated beverages or alcohol near bedtime (eg, late afternoon and evening), smoking or other nicotine intake particularly during the evening, stimuli in the sleep environment (eg, ambient light, television, or radio), persistent concerns or worries at bedtime, lack of exercise, and frequent daytime naps (especially those that are longer than 20 to 30 minutes or occur late in the day).
●Medications – Many medications commonly prescribed in older adults can be associated with poor sleep and excessive daytime sleepiness (eg, narcotics, benzodiazepines, beta blockers, antidepressants, diuretics). Beta blockers and donepezil are also relatively common causes of nightmares in adults [44].
●Comorbidities – Many medical and psychiatric illnesses that are common in older adults can also disrupt sleep. These include heart failure, chronic obstructive pulmonary disease, depression, anxiety, dementia, gastroesophageal reflux disease, and neuromuscular disorders (eg, amyotrophic lateral sclerosis, multiple sclerosis). (See "Sleep-wake disturbances and sleep disorders in patients with dementia" and "The effect of sleep in patients with neuromuscular and chest wall disorders" and "Evaluation of sleep-disordered breathing in patients with neuromuscular and chest wall disease".)
SUMMARY AND RECOMMENDATIONS
●Sleep-related complaints are common among older adults (ie, adults >65 years old). The clinician needs to be able to determine the likely etiology of sleep impairment in this population so that appropriate testing and prompt treatment can occur. (See 'Introduction' above.)
●Evaluation – When evaluating sleep in the older adult, we determine whether the patient’s symptoms are consistent with normal aging, a primary sleep condition, or other issues of sleep impairment common in older adults (eg, poor sleep hygiene, medications, and comorbid illnesses). (See 'Evaluating sleepiness in older adults' above.)
•In patients whose complaints are mild and/or consistent with normal aging, we do not typically perform diagnostic testing or treatment. Sleep-related changes that are a normal consequence of aging are listed in the table (table 4). In brief, older adults tend to complain of difficulty maintaining sleep, resulting in increased daytime sleepiness and napping. A propensity for daytime napping (eg, falling asleep in a chair late evening) should not be confused with excessive daytime sleepiness (EDS; eg, falling asleep while talking with someone, getting dressed, eating a meal, going to the bathroom). The Epworth sleepiness scale (calculator 1) may be helpful in this distinction with a score above 10 suggesting primary sleep pathology rather than normal aging effects on sleep. (See 'The normal effects of aging on sleep' above.)
•In patients whose complaints seem out of proportion to normal aging (ie, consistent with EDS) or patients who have other symptoms or signs of a primary sleep disorder, we typically perform diagnostic testing to look for coexisting sleep disorders that require treatment. This typically involves some basic laboratory tests including a complete blood count, routine chemistries, and thyroid function tests. If not revealing, we typically perform a sleep study (in-home or in-laboratory). (See 'Symptoms disproportionate with normal aging or consistent with a sleep disorder' above.)
•We evaluate patients with history of stroke or transient ischemic attack and patients with early dementia for features of sleep disordered breathing, and have a low threshold to perform formal sleep testing in those with any symptoms or signs suggesting a sleep disorder. (See 'Others' above.)
●Common sleep disorders – Common sleep disorders in the older adult which warrant investigation include the following:
•Sleep apnea – Obstructive sleep apnea and, less commonly, central sleep apnea, are the most common disorders of sleep in later life. (See 'Sleep apnea' above.)
-The incidence of sleep apnea rises with age. Untreated sleep apnea in older adults has been associated with increased risk of stroke, mild cognitive defects, and dementia. Evidence to support an impact of untreated sleep apnea on mortality, coronary artery disease, and hypertension is unclear. (See 'Incidence' above and 'Natural history' above.)
-The symptoms are similar to those in younger adults, except cognitive abnormalities and nocturia may be more frequent in older adults. Indications for diagnostic evaluation are also similar to younger adults. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults".)
-The management of sleep apnea in older adults is similar to the management in younger adults, with positive airway pressure (PAP) as the mainstay of treatment. However, therapy is more challenging in older adults for several reasons including recurrent nocturnal awakenings, difficulty with interface or oral appliance fit, a greater need for education to enhance adherence, and comorbidities that prohibit select approaches (eg, poor surgical candidacy). Therapy improves daytime sleepiness but its impact on quality of life measures or other outcomes is unclear. (See 'Treatment' above.)
•Insomnia – Insomnia may occur in association with comorbid conditions that are common in later life such as chronic pain from arthritis, nocturia from prostatic hypertrophy, psychiatric conditions (eg, dementia, depression, and anxiety), night sweats from menopause, or precipitating events (eg, loss of a loved one). Evaluation and treatment are similar to younger adults with a stronger emphasis on cognitive behavioral therapy. (See "Evaluation and diagnosis of insomnia in adults" and "Overview of the treatment of insomnia in adults", section on 'Older adults'.)
•Others – Other disorders that are less common in older adults include circadian rhythm sleep disorder, rapid eye movement (REM) behavior disorder, restless leg or periodic limb movement disorder. Evaluation and management are similar to younger adults. (See "Overview of circadian sleep-wake rhythm disorders" and "Rapid eye movement sleep behavior disorder" and "Clinical features and diagnosis of restless legs syndrome and periodic limb movement disorder in adults" and "Management of restless legs syndrome and periodic limb movement disorder in adults" and "Sleep-wake disturbances and sleep disorders in patients with dementia".)
●Poor sleep hygiene, medications, comorbidities – In patients whose poor sleep habits, medications, or comorbidities explain or contribute to sleep-related complaints, the underlying issues should be addressed. This includes evaluating and treating for lifestyle changes (ie, poor sleep hygiene), medications (eg, narcotics, benzodiazepines, beta blockers, antidepressants, diuretics), medical illnesses (heart failure, chronic obstructive pulmonary disease, dementia, neuromuscular disorders), and psychiatric illnesses (depression, anxiety). (See 'Sleep hygiene, medications, and comorbidity issues' above.)
