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Once thought of as a "passive, dormant" part of daily life,1 sleep is now understood to include vital physiologic processes: it helps to "maintain mood, memory, and cognitive performance [and] plays a pivotal role in the normal function of the endocrine and immune systems."2 But many older adults may not be getting adequate sleep. In 2003 the National Sleep Foundation polled 1,506 older adults ages 55 to 84 and found that about two-thirds had one or more symptoms of a sleep problem "at least a few nights a week."3 The prevalence of insomnia rises with age, affecting 23% to 41% of adults ages 70 and older, with women ages 80 to 89 having the highest prevalence rate, according to one review.4 And a large epidemiologic study of more than 9,000 adults ages 65 and older found that more than half reported at least one chronic sleep problem "occurring most of the time."5


Sleep disturbances or deprivation or both have been linked with a range of negative outcomes, including compromised endocrine and immune function, cognitive impairment, hypertension, impaired healing of damaged tissues, and obesity, among others.2,6,7 One study found that sleep duration and quality were predictors of glycemic control in patients with type 2 diabetes.6 When the patients' quality of sleep improved, their glycemic control (as measured using glycosylated hemoglobin levels) improved also. A recent review found that 17 of 23 cross-sectional studies in adults "supported an independent association between short sleep duration and increased weight," although the strength of the association waned with age.8 In the Cardiovascular Health Study, 5,201 adults 65 years of age and older were surveyed regarding sleep disturbance. The researchers concluded that people with "confirmed angina were 1.6 times more likely to report difficulty falling asleep," although it wasn't clear whether poor sleep caused or resulted from the heart condition.9 The National Institute for Neurological Disorders and Stroke notes that sleep deprivation can cause or exacerbate confusion, depression, and pain.10 A lack of or inadequate sleep contributes to slowed responses and difficulty concentrating and making decisions, which may explain in part why older adults who sleep poorly fall more often in the home11 and have more accidents while driving.1


What are the costs associated with poor sleep? Insomnia's fiscal costs are wide ranging. They stem from vehicular accidents caused by driver fatigue, work accidents related to fatigue-related attention deficits, sleep assessments, and pharmacologic and nonpharmacologic interventions to treat sleep disturbances. A 1994 review of the economic effects of insomnia estimated its annual fiscal cost to be $92.5 billion to $107.5 billion in the United States alone.12 The current annual cost is probably higher. In a recent retrospective study of 75,558 elderly patients with insomnia and 75,558 without insomnia, researchers determined that direct health care costs-inpatient, outpatient, ED, and pharmacy costs for all diseases within a six-month period-averaged $1,143 higher among patients with insomnia than among controls.13


Early detection and intervention for sleep disturbances among older adults can likely help reduce the financial burden associated with sleep-related accidents and illness and promote better quality lives.12,13 (For a related article, see Sleep Disruption in Older Adults, May 2007.)


Watch It!!

Go to to watch a nurse use the Pittsburgh Sleep Quality Index to assess sleep quality in a hospitalized patient and discuss how to administer it and interpret results. Then watch the health care team plan interventions.


View this video in its entirety and then apply for CE credit at; click on the How to Try This series link. All videos are free and in a downloadable format (not streaming video) that requires Windows Media Player.


For more information on this and other geriatric assessment tools and best practices go to clinical Web site of the Hartford Institute for Geriatric Nursing, New York University College of Nursing, and the Nurses Improving Care for Healthsystem Elders (NICHE) program.


Visit the Hartford Institute site,, and the NICHE site,, for additional products and resources. For example, on the Hartford site you will find an interactive clinical vignette called "Geriatric Syndromes-Falls and Nutrition/Fluids" that includes use of the Katz ADL and Lawton IADL tools.


Go to and click on the How to Try This link to access all articles and videos in this series.




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2. National Sleep Foundation. Sleep-wake cycle: its physiology and impact on health. Washington, D.C.; 2006. [Context Link]


3. National Sleep Foundation. 2003 Sleep in America poll. Washington, D.C.; 2003 Mar 10. [Context Link]


4. Lichstein KL, et al. Insomnia in the elderly. Sleep Med Clin 2006;1(2):221-9. [Context Link]


5. Foley DJ, et al. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep 1995;18(6):425-32. [Context Link]


6. Knutson KL, et al. Role of sleep duration and quality in the risk and severity of type 2 diabetes mellitus. Arch Intern Med 2006;166(16):1768-74. [Context Link]


7. Flaherty JH. Insomnia among hospitalized older persons. Clin Geriatr Med 2008;24(1):51-67. [Context Link]


8. Patel SR, Hu FB. Short sleep duration and weight gain: a systematic review. Obesity (Silver Spring) 2008. [Context Link]


9. Newman AB, et al. Sleep disturbance, psychosocial correlates, and cardiovascular disease in 5201 older adults: the Cardiovascular Health Study. J Am Geriatr Soc 1997;45(1):1-7. [Context Link]


10. National Institute of Neurological Disorders and Stroke. National Institutes of Health. Brain basics: understanding sleep. Bethesda, MD; 2007 May 21. NIH Publication No.06-3440-c. [Context Link]


11. Brassington GS, et al. Sleep problems as a risk factor for falls in a sample of community-dwelling adults aged 64-99 years. J Am Geriatr Soc 2000;48(10):1234-40. [Context Link]


12. Stoller MK. Economic effects of insomnia. Clin Ther 1994;16(5):873-97; discussion 854. [Context Link]


13. Ozminkowski RJ, et al. The direct and indirect costs of untreated insomnia in adults in the United States. Sleep 2007;30(3):263-73. [Context Link]