Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine and the University of New Mexico Hospital Sleep Disorders Center, Albuquerque, NM
An estimated 19 million individuals in the US will be over 85 years of age by 2050 (5% of the total population), and 2 million will be have reached the status of centenarians. Nonetheless, geriatric medicine continues to be a vastly under-represented specialty. In work environments where clinical productivity is often of paramount concern, it is difficult for many of us to keep up with the latest in general practice, let alone geriatric medicine, and the even more specialized field of geriatric sleep medicine may be ignored completely. From my perspective as a fellowship-trained geriatric and sleep medicine physician, Principles and Practice of Geriatric Sleep Medicine is a delightful book “done right” in terms of filling in this much-needed gap. The text is filled with examples, pictures, graphs, stories, and so many intriguing pages that I found myself enticed into reading some chapters twice.
Part 1 covers the effects of normal aging on sleep. The content begins with an intriguing discussion of how aging may alter circadian rhythms, and subsequent chapters continue with practical information to help the reader understand other normal physiological changes of aging. These changes encompass such basic bodily functions as thermoregulation, gastrointestinal and genitourinary function, and the neuroendocrine axes. There follows, in chapter 7, a splendid description of upper airway anatomy and function in the elderly, and concludes with the provocative hypothesis that obstructive sleep apnea (OSA) may actually represent a protective mechanism in those over the age of 70 years.
Part 2 focuses on neuroendocrine and homeostatic alterations in the elderly. The chapter on melatonin and dementia is home to a splendid graph on the declining levels of melatonin throughout life; for visual learners, this will surely provide a long-lasting “teachable moment.” The text then adds profound insight into how elders, particularly those with neurodegenerative disorders, may be affected by these declining levels. There are also important clinical lessons to be drawn from this reduction in melatonin secretion that this book highlights. All too often, physicians in training overwhelm those elderly suffering from insomnia with non-benzodiazepine hypnotics starting at full strength and move on to benzodiazepines, thinking those with the longest half-life are better. This regrettably overlooks the crucial fact that the decline in melatonin represents an easy and obvious target for treating insomnia in this population, namely the administration of exogenous melatonin at an appropriate time in the evening.
Parts 3 and 4 of Principles and Practice of Geriatric Sleep Medicine incorporate chapters examining virtually every specific sleep disorder from the perspective of diagnosis and management in the aging individual. Of particular note are excellent discussions of the judicious and appropriate use of pharmacologic agents for the specific sleep/wake diagnoses being covered in each chapter, with extensive analysis of currently available options. The authors bring out key principles that are often missed in prescribing for the elderly, such as slower medication elimination, a higher likelihood of preexisting cognitive impairment, a predisposition to develop cognitive impairment as a side effect, and adverse interactions with concurrent medications. The importance of falls in the elder cannot be overemphasized, and several authors discuss the implications of this risk from various perspectives.
No book relating to geriatric medicine would be complete without thorough discussions of Parkinson disease and Alzheimer disease. The authors do a splendid job discussing the sleep-related pathophysiology of these disorders, including effects on circadian rhythms, the evaluation of sleep disorders in neurodegenerative disease (in particular, REM sleep behavior disorder or RBD), and treatment considerations.
In the final analysis, Principles and Practice of Geriatric Sleep Medicine is an invaluable contribution to the educational armamentarium of sleep medicine, particularly at the bargain price for which it sells. It should be required reading for every geriatric fellow, gerontologist, and sleep medicine physician—indeed, for anyone wishing to increase their knowledge of sleep and sleep/wake disorders in the elderly. Although I find myself wanting to lend it to a well-deserving resident or fellow, I am holding onto it tightly as there still remain a few chapters that I wish to read one more time…well, maybe even twice more.
The author has indicated no financial conflicts of interest.
Ralls FM. Principles and practice of ge riatric sleep medicine. J Clin Sleep Med 2013;9(4):411-412.