Fragmentation of the senile dream

Specialty: Geriatrics.

• destructuring of the sleep pattern
• insomnia due to senile circadian disruption
• repetitive nocturnal awakening
• fragmented insomnia of the elderly

Why it occurs

• Progressive calcification of the pineal gland associated with age with a drastic reduction in nocturnal melatonin secretion
• Lack of external circadian stimuli and synchronizers due to little exposure to daytime sunlight and extreme sedentary lifestyle
• Presence of severe nocturia or nocturnal polyakiuria secondary to benign prostatic hyperplasia or overactive bladder
• Restless legs syndrome or periodic movements of the lower extremities during sleep with frequent microawakenings
• Chronic osteoarticular pain secondary to osteoarthritis or neuropathies that intensifies when lying down at night

Initial workup

Daily sleep log (sleep diary completed by caregiver or patient for a minimum period of 2 weeks); wrist actigraphy to objectify activity-rest cycles; Complete nocturnal polysomnography if there is suspicion of obstructive sleep apnea or REM sleep behavior disorders; analytical determination of serum ferritin (rule out iron deficiency as a cause of restless legs syndrome); Renal and bladder ultrasound with measurement of voiding residue if nocturia predominates.

Standard management

• Extended release melatonin — 2 mg orally administered 1 to 2 hours before the expected time to fall asleep, in order to imitate the physiological peak and reduce fragmentation, avoiding daytime sleepiness
• Trazodone — 25 mg to 50 mg orally at night, excellent non-benzodiazepine alternative with low anticholinergic load and no risk of habituation or physical dependence
• Gabapentin — 100 mg to 300 mg orally at night in case of concomitant nocturnal neuropathic pain or refractory restless legs syndrome, controlling morning sleepiness and risk of falls
• Avoid the use of benzodiazepine hypnotics (such as lorazepam, lormetazepam or diazepam) or "Z" drugs (such as zolpidem) due to their high risk of inducing delirium, cognitive impairment and falls according to the Beers criteria.