A 79-year-old woman comes to the office for her yearly checkup. She reports feeling well physically but mentions some sleep issues. The patient used to sleep 8-9 hours a night. Now, she wakes up in the middle of the night and arises an hour earlier than she used to, around 5:30 AM. She has little difficulty falling asleep and does so most evenings while sitting and watching television. She gets a total of 6½ to 7 hours of sleep and often awakens 1 or 2 times to go to the bathroom, returning to sleep within 10-15 minutes. The patient's husband says that she snores softly but reports no breathing pauses, gasping, or choking. During daytime hours, the patient has energy in the morning but often takes a 30- to 45-minute nap in the afternoon. She reports no persistent anxiety or depression. She has a good appetite and is able to follow television programs, concentrate on crossword puzzles, and likes to go out with friends in the morning. Medical conditions include osteoporosis and arthritis. Medications include alendronate and ibuprofen as needed. The patient does not use alcohol or illicit drugs. Blood pressure is 124/82 mm Hg, pulse is 66/min, and respirations are 14/min. BMI is 27 kg/m². In addition to sleep hygiene education, which of the following is the next best step regarding this patient's sleep?

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This patient's sleep pattern is consistent with normal aging. Changes in sleep architecture that can occur with age include increased nighttime sleep onset latency, decreased REM latency, and decreased slow-wave sleep. Patients can experience decreased total sleep time, peak sleepiness earlier in the evening, nocturnal awakenings, reduced sleep during early-morning hours, and daytime napping/reduced daytime sleep latency, as seen in this patient. Due to these changes, elderly patients may experience difficulty falling asleep and/or maintaining sleep. Provided that patients do not have significant impairment in activities of daily living or cognition, no further workup is necessary, and they should be reassured that these changes are normal. However, when insomnia is functionally impairing, nonpharmacologic interventions and cognitive-behavioral therapy are used first line. Pharmacotherapy is generally limited to short-term management. (Choices A and B) Benzodiazepines (eg, lorazepam) and nonbenzodiazepine hypnotics (eg, zolpidem) are not indicated in this patient with normal, age-related sleep changes. The elderly are at a particularly high risk of adverse effects from hypnotic medications. Therefore, these medications should be avoided if possible because they are associated with an increased risk of delirium, impaired cognition, over sedation, falls, and fractures. (Choices C and E) Although these medications could be considered for patients with diagnosed insomnia, they are not indicated for this patient with normal sleep changes and no evidence of daytime impairment. Melatonin may have some, albeit limited, efficacy in the treatment of some circadian rhythm disorders (eg, delayed sleep-wake phase disorder) and sleep onset insomnia in the elderly. This patient does not have any sleep onset insomnia. Ramelteon, a melatonin agonist used for sleep onset insomnia, has demonstrated safety in older adults and could be considered when nonpharmacological interventions are ineffective. (Choice D) Polysomnography may help rule out possible underlying etiologies of disrupted sleep when the cause is less clear. However, this patient has classic symptoms of normal, age-related sleep changes and does not snore loudly or have breathing pauses. (Choice G) Sleep restriction therapy is a nonpharmacologic treatment for patients with insomnia who spend too much nonsleeping time in bed; this patient does not have insomnia and does not spend excessive time in bed. Educational objective: Normal, age-related sleep changes include decreased total sleep time; increased nighttime awakenings; sleepiness earlier in the evening with early morning awakening; and increased daytime somnolence (napping). References: Aging and sleep: physiology and pathophysiology. (http://www.ncbi.nlm.nih.gov/pubmed/20941662) Modelling changes in sleep timing and duration across the lifespan: changes in circadian rhythmicity or sleep homeostasis? (http://www.ncbi.nlm.nih.gov/pubmed/26545247)

A 79-Year-Old Woman Comes to the Office for Her Yearly