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Sleep and Cognition: Implications among
the Elders
Thomas B. Virden III, Ph.D., ABPP
Arizona Neuropsychological Association
September 15, 2018
Objectives!
• Identify at least 3 aspects of cognition impacted by sleep patterns
• Identify sleep patterns most deleterious to cognitive functioning
• Identify sleep patterns most advantageous to cognitive
functioning
Bad Sleep is Bad
• Insomnia and sleep duration problems common in elders
• Poor sleep is reported in about 50% of individuals 65 and older
• Poor sleep in elders is often linked to:– Depression
– Suicide
– Cardiovascular disease
– General mortality
– Functional impairment
– Low quality of life
– Increased use of sleep aids
• Contributes to falls
Cognitive Decline
• Short night sleep and frequent daytime naps lead to decrements
in:
– Vigilance
– Recall
– Processing speed
– Executive functioning
– Attention
– Concentration
– Visual memory
Do you know how much (or little)
you sleep?• People often underestimate their sleep
• Reports of poor or little sleep, when recordings are quite normal
• 105 individuals 60 and over were give nap opportunities
– 40% did not perceive at least 2 naps
• That 40% were more likely to score 26 or less on the MMSE
• Nocturia in half adults 66 and older
– 21% in men and 27% in women over 20
– More nocturia means less sleep quality (Fung, et al. 2017)
Nguyen-Michel, et al. (2015)
Fung, et al. (2017).
In the Brain
• Slow wave sleep seems to benefit
– Prefrontal cortex
– Hippocampus
• Possibly impacting PFC and HPC dependent cognition
– Thus, poor sleep may be more likely to impact that area of cognitive functioning
– Working memory
– Inhibition
– Controlled processing speed
– Memory and recall
Memory Issues, Maybe Not an
Issue?• In home monitoring studies:
– 48-55 SWS decline relates to memory decline
– 55 and older get less SWS
• But does not correlate to memory decline
– Decoupling of memory with SWS in older adults
Scullin, M. K. (2013)
But the PFC…!
• Sleep continuity seems to be the culprit in those 55 and older
• With more continuity comes better
– Inhibitory control
– Memory recall
– Verbal fluency
Wilckens, et al., (2014)
Length Matters
• Short and long sleep duration is linked to:
– Increased mortality
– Stroke
– Diabetes
– Heart disease
– Depression
Chicken and Egg?
• 7 year longitudinal study of 3,820 individuals 60 and over.
• Higher mortality rate for those with a sleep duration of over 10
hours
• Controlling for
– General health
– Cognitive functioning
– Quality of Life
– Depression
Mesas, López-García, León-MuñozGuallar-Castillón, &
Rodríguez-Artalejo (2010).
Sleep Duration and Cognitive
Impairment• 695 men and women aged 40-65 in Germany
– If sleep remained stable, no problem
– If sleep increased 7h to 8.5 hours over a couple of years
• Decreased cognitive functioning.
• 500 men and women aged 60 and older in Turkey
– Less than 6 hours per night
– Daytime sleepiness lasting 1 hour or more
Loerbroks, Debling, Amelang, & Stürmer (2010).
Soykok, et al. (2017).
The Bronx Aging Study
• 375 men and women 75-85
• Controlled for
– hypnotic medications
– physical morbidity
– Education
• Those who reported longer sleep duration did worse on verbal
short term memory tests
Schmutte, et al. (2007)
Individual Deviations
• 50 African American individuals aged 50-80
• Self-report sleep duration and quality
• Tests of cogntitive functioning over 2-3 weeks:
– Stroop
– Clock drawing
– Rey AVLT
• The more someone deviated from the average sleep duration, the
more pronounced cognitive decline became.
Gamaldo, Allaire, & Whitfield (2010)
7 +/-2?
• 15,385 Nurses 70 years and older over a 6 year period
– 5 hours per day worse cognition than those sleeping 7 hours per day
– 9 hours per day worse cognition than those sleeping 7 hours per day
– A decrease in cognitive functioning was also noted if sleep deviated from
their average by 2 hours or more.
Devore, et al. (2014).
Is Napping a Problem?
• In the VA, 192 men aged 60 and over
– Sleep monitors and MMSE
– 6 month follow up
• If daytime napping decreased within that 6 month period,
cognition improved
– Daytime wakefulness did not seem to have an impact
Dzierzewski, et al. (2014).
Napping Healthily
• 2,974 Men and Women aged 63 and older in China
• Controlled for BMI, depression, nighttime sleep duration
• 4 Post lunch napping categories
– Non nappers
– Short nappers (less than 30 minutes)
– Moderate nappers (30-90 minutes)
• Average nap among all nappers was 63 minutes
– Extended nappers (90 minutes or more)
• Moderate nappers fared on cognition better than both extended and non nappers
• Short nappers fared better than non nappers
Li, et al. (2017)
A Nonpharmacological
Treatment?• Exercise and cognitive stimulation
• 126 subjects 65 and older with low levels of activity
– Less than 2 days per week
• Combinations of 4 treatments:
– Stretching
– Aerobics
• 60 min 3x week
– Sensorimotor games
• Tracking movement
• Matching tones Pa, et al.. (2014)
More Exercise and Cognition!
(With a bit of Light)
• Educational lectures
– Art, History, Science
– Multiple choice quizzes at the end
• Improvements in all groups according to the Sleep Disorders
Questionnaire
– Stretching + Education had the best effect
• Light therapy has also shown to be moderately effective in
improving sleep in cognitively impaired individuals
– No measures on cognitive improvement, howeverChiu, et al. (2017)
Pa, et al.. (2014)
In Sum: Aspects of Cognition
• Prefrontal and Hippocampal aspects of cognition appear most
impacted by sleep
– Working memory
– Inhibition
– Recall
– Processing speed
– Moreso in PFC in elders
Deleterious Sleep Patters
• Too little or too much!
• Deviations from your own average duration
• Excessive napping
Advantageous Sleep Patterns
• ‘Healthy’ seems individualistic, but there appears to be a range
– More than 5, less than 9
• Continuity!
• While napping a great deal may be problematic, keeping it within
a 30-90 minute range may be better than not napping at all
Any Questions Keeping You
Awake Tonight?
References
Carlson, B. W., Neelon, V. J., Carlson, J. R., Hartman, M., & Bliwise, D. L. (2011). Cerebral Oxygenation in Wake and During Sleep and Its Relationship to
Cognitive Function in Community-Dwelling Older Adults Without Sleep Disordered Breathing. Journals Of Gerontology: Series A: Biological Sciences
And Medical Sciences, 66A(1), 150-156.
Chiu, H. L., Chan, P. T., Chu, H., Hsiao, S. S., Liu, D., Lin, C. H., & Chou, K. R. (2017). Effectiveness of Light Therapy in Cognitively Impaired Persons: A
Metaanalysis of Randomized Controlled Trials. Journal Of The American Geriatrics Society, 65(10), 2227-2234.
Devore, E. E., Grodstein, F., Duffy, J. F., Stampfer, M. J., Czeisler, C. A., & Schernhammer, E. S. (2014). Sleep Duration in Midlife and Later Life in
Relation to Cognition. Journal Of The American Geriatrics Society, 62(6), 1073-1081.
Dzierzewski, J. M., Fung, C. H., Jouldjian, S., Alessi, C. A., Irwin, M. R., & Martin, J. L. (2014). Decrease in Daytime Sleeping Is Associated with
Improvement in Cognition After Hospital Discharge in Older Adults. Journal Of The American Geriatrics Society, 62(1), 47-53
Fung, C. H., Vaughan, C. P., Markland, A. D., Huang, A. J., Mitchell, M. N., Bliwise, D. L., Ancoli-Israel, S., Redline, S., Alessi, C. A., & Stone, K. (2017).
Nocturia is Associated with Poor Sleep Quality Among Older Women in the Study of Osteoporotic Fractures. Journal Of The American Geriatrics Society, 65(11), 2502-2509. doi:10.1111/jgs.15027
Gamaldo, A. A., Allaire, J. C., & Whitfield, K. E. (2010). Exploring the Within-Person Coupling of Sleep and Cognition in Older African Americans.
Psychology And Aging, 25(4), 851-857.
More References
Li, J., Cacchione, P. Z., Hodgson, N., Riegel, B., Keenan, B. T., Scharf, M. T., Richards, K., & Gooneratne, N. S. (2017). Afternoon Napping and
Cognition in Chinese Older Adults: Findings from the China Health and Retirement Longitudinal Study Baseline Assessment. Journal Of The American
Geriatrics Society, 65(2), 373-380.
Loerbroks, A., Debling, D., Amelang, M., & Stürmer, T. (2010). Nocturnal sleep duration and cognitive impairment in a population-based study of older
adults. International Journal Of Geriatric Psychiatry, 25(1), 100-109.
Mesas, A. E., López-García, E., León-Muñoz, L. M., Guallar-Castillón, P., & Rodríguez-Artalejo, F. (2010). Sleep duration and mortality according to health
status in older adults. Journal Of The American Geriatrics Society, 58(10), 1870-1877. doi:10.1111/j.1532-5415.2010.03071.x
Nguyen-Michel, V., Lévy, P., Pallanca, O., Kinugawa, K., Banica-Wolters, R., Sebban, C., Mariani, J, Fournier, E. & Arnulf, I. (2015). Underperception of
Naps in Older Adults Referred for a Sleep Assessment: An Insomnia Trait and a Cognitive Problem?. Journal Of The American Geriatrics Society, 63(10),
2001-2007.
Pa, J., Goodson, W., Bloch, A., King, A. C., Yaffe, K., & Barnes, D. E. (2014). Effect of Exercise and Cognitive Activity on Self-Reported Sleep Quality in
Community-Dwelling Older Adults with Cognitive Complaints: A Randomized Controlled Trial. Journal Of The American Geriatrics Society, 62(12), 2319-
2326.
Does this guy sleep?
Schmutte, T., Harris, S., Levin, R., Zweig, R., Katz, M., & Lipton, R. (2007). The Relation Between Cognitive Functioning and Self-Reported Sleep
Complaints in Nondemented Older Adults: Results From the Bronx Aging Study. Behavioral Sleep Medicine, 5(1), 39-56.
doi:10.1207/s15402010bsm0501_3
Scullin, M. K. (2013). Sleep, Memory, and Aging: The Link Between Slow-Wave Sleep and Episodic Memory Changes From Younger to Older Adults.
Psychology and Aging, 28(1), 105-114.
Soykok, G., Yilmaz, R., Senturk, A. I., Cevic, S., Figul Gocke, S., Kayim Yildiz, O., & Toaktas, S. (2015). Association of sleep quality and daytime
sleepiness with cognition in the elderly. Turkish Journal Of Geriatrics / Türk Geriatri Dergisi, 18(2), 123-129.
Wilckens, K. A., Woo, S. G., Kirk, A. R., Erickson, K. I., & Wheeler, M. E. (2014). Role of Sleep Continuity and Total Sleep Time in Executive Function
Across the Adult Lifespan. Psychology And Aging, 29(3), 658-665.